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ID
6363
Description
TL Radiation Therapy Oncology Group Protocol Calculation Form Interstitial Brachytherapy With or Without External-Beam Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA894E4A-1A32-58C1-E034-0003BA12F5E7
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Versions (3)
- 12/18/14 12/18/14 - Martin Dugas
- 6/2/15 6/2/15 -
- 6/3/15 6/3/15 -
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December 18, 2014
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License
Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT00063882 Treatment - TL Radiation Therapy Oncology Group Protocol Calculation Form - 2058421v3.0
INSTRUCTIONS: Submit this form with initial dosimetry data. If additional boost fields are given, complete form again to include all additional data and send with final dosimetry data.
- StudyEvent: TL Radiation Therapy Oncology Group Protocol Calculation Form
Similar models
INSTRUCTIONS: Submit this form with initial dosimetry data. If additional boost fields are given, complete form again to include all additional data and send with final dosimetry data.
- StudyEvent: TL Radiation Therapy Oncology Group Protocol Calculation Form
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,First
Item
Patient's Name
text
PatientStudyID,CoordinatingGroup
Item
Patient's I.D. No.
text
RTSite,LocationName
Item
Anatomical Treatment Area
text
CL Item
Rt Field (FIELD I)
CL Item
Rt Field (FIELD II)
CL Item
Rt Field (FIELD III)
CL Item
Rt Field (FIIELD IV)
CL Item
Rt Field (FIELD V)
CL Item
Rt Field (FIELD VI)
Fieldprojection
Item
Field projection (ant, lat, oblique, etc.)
text
Manufacturernameandunitenergy
Item
Manufacturer name and unit energy
text
Monitorunits/minutes
Item
Monitor units/minutes
text
Tumordoseperfieldforeachfield@pointofprotocolprescription
Item
Tumor dose per field for each field at point of protocol prescription
text
SSD/SAD
Item
SSD/SAD (cm)
text
Treatmentdepth
Item
Treatment depth (cm)
text
Collimatorsetting
Item
Collimator setting (Field size in cm at isocenter)
text
EquivalentsquareatSSD/SAD
Item
Equivalent square at SSD/SAD
text
%DD,TAR,TMR,TPR,TOR
Item
% DD, TAR, TMR, TPR, TOR (indicate as applicable)
text
Item
Beam output factor for treatment field size (include calibration distance factor if applicable)
text
Code List
Beam output factor for treatment field size (include calibration distance factor if applicable)
CL Item
Cgy/mu (CGY/MU)
CL Item
Cgy/min (CGY/MIN)
CGY/MU(beamoutputfactor)
Item
CGY/MU (beam output factor) (Linac)
text
CGY/MIN(beamoutputfactor)
Item
CGY/MIN (beam output factor) (cobalt)
text
CL Item
Wedge (Wedge)
CL Item
Tray (Tray)
CL Item
Comp (Comp)
CL Item
Other, Specify (Other, specify)
Wedge(transmissionfactors)
Item
Wedge (transmission factors)
text
Tray(transmissionfactors)
Item
Tray (transmission factors)
text
Comp(transmissionfactors)
Item
Comp (transmission factors)
text
other,specify
Item
Other, specify (transmission factors)
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
PersonCompletingForm,FirstName
Item
Form completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date
date
Item Group
Ccrr Module For Tl Radiation Therapy Oncology Group Protocol Calculation Form