ID
6480
Description
E3F05 Chemotherapy Form - Arm B Only Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma NCT00978458 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6D055B43-63F1-A6F7-E040-BB89AD436A92
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 1/1/15 1/1/15 - Martin Dugas
Uploaded on
January 1, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00978458 Treatment - E3F05 Chemotherapy Form - Arm B Only - 2904374v1.0
INSTRUCTIONS: Complete this form at the end of radiation/chemoradiation therapy, at the end of cycles 1, 2, 3, and at the end of cycles 6 (covering cycles 4-6), 9 (covering cycles 7-9) and 12 (covering cycles10-12). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule
- StudyEvent: E3F05 Chemotherapy Form - Arm B Only
Description
Vital Status
Description
Patient Status
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-1
- C3846084
- NCI Thesaurus ValueDomain
- C18003
- NCI Thesaurus ValueDomain-2
- C25688
- NCI Thesaurus Property
- C25717
Description
Date last contact
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-1
- C0805839
- NCI Thesaurus Property
- C25461
- NCI Thesaurus Property-2
- C25551
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25367
Description
Primary Cause of Death
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS CUI-1
- C0007465
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C28554
- NCI Thesaurus ValueDomain-2
- C25251
Description
Cause of Death, specify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS CUI-1
- C0007465
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C1521902
- NCI Thesaurus Property
- C28554
Description
Patient Characteristics
Description
Patient Weight
Data type
float
Measurement units
- Kg
Alias
- NCI Thesaurus ValueDomain
- C25209
- UMLS CUI-1
- C0005910
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25208
Description
Body Surface Area
Data type
float
Measurement units
- m2
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS CUI-1
- C0005902
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus Property
- C25157
Description
Therapy Administered
Alias
- UMLS CUI-1
- C0087111
Description
Agent
Data type
text
Alias
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1521826
- NCI Thesaurus ObjectClass
- C1708
- NCI Thesaurus ValueDomain
- C1708
- NCI Thesaurus ValueDomain-2
- C42614
Description
Agent administered during reporting period
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS CUI-1
- C0450442
- NCI Thesaurus ObjectClass
- C1708
- UMLS CUI-2
- C1521801
- NCI Thesaurus Property
- C25382
Description
Agent dose prescribed
Data type
float
Alias
- NCI Thesaurus ObjectClass
- C28180
- NCI Thesaurus ObjectClass-2
- C1708
- NCI Thesaurus Property
- C25256
- NCI Thesaurus ValueDomain
- C25488
- NCI Thesaurus ValueDomain-2
- C1708
- UMLS CUI-1
- C0678766
- UMLS CUI-2
- C0278329
Description
Agent dose administered
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C1708
- UMLS CUI-1
- C0678766
- NCI Thesaurus Property
- C25616
- UMLS CUI-2
- C1521801
- NCI Thesaurus Property-2
- C25375
- NCI Thesaurus Property-3
- C25431
- NCI Thesaurus Property-4
- C25256
- NCI Thesaurus ValueDomain
- C25488
Description
Agent day count
Data type
float
Alias
- NCI Thesaurus ValueDomain
- C25301
- UMLS CUI-1
- C0450442
- NCI Thesaurus Property
- C25639
- UMLS CUI-2
- C0439228
- NCI Thesaurus ValueDomain-2
- C25463
- UMLS CUI-3
- C0750480
- NCI Thesaurus ObjectClass
- C1708
Description
Agent Total Dose
Data type
float
Alias
- NCI Thesaurus ValueDomain
- C25304
- UMLS CUI-1
- C2986497
- NCI Thesaurus Property
- C25379
- NCI Thesaurus ValueDomain-2
- C25488
- NCI Thesaurus ObjectClass
- C1708
Description
Patient Diary complete
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS CUI-1
- C3259162
- NCI Thesaurus Property
- C25250
- NCI Metathesaurus ObjectClass
- C0030705
Description
Reason for agent not administered
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS CUI-1
- C0566251
- NCI Thesaurus Property
- C25594
- UMLS CUI-2
- C1299369
- NCI Thesaurus ObjectClass
- C25488
- NCI Thesaurus Property-2
- C25382
Description
Dose Modification Reason, other
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS CUI-1
- C1707811
- NCI Thesaurus ObjectClass
- C25488
- UMLS CUI-2
- C3840932
- NCI Thesaurus Property
- C25572
Description
Non-protocol Therapy
Description
Non-protocol therapy
Data type
boolean
Alias
- NCI Thesaurus ObjectClass
- C25590
- UMLS CUI-1
- C1518384
- NCI Thesaurus ObjectClass-2
- C16212
- UMLS CUI-2
- C0087111
- NCI Thesaurus Property
- C25320
- NCI Thesaurus Property-2
- C49236
- NCI Thesaurus Property-3
- C25456
- NCI Thesaurus Property-4
- C25382
- NCI Thesaurus ValueDomain
- C38148
Similar models
INSTRUCTIONS: Complete this form at the end of radiation/chemoradiation therapy, at the end of cycles 1, 2, 3, and at the end of cycles 6 (covering cycles 4-6), 9 (covering cycles 7-9) and 12 (covering cycles10-12). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule
- StudyEvent: E3F05 Chemotherapy Form - Arm B Only
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
C3242370 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C2045829 (UMLS CUI-1)
C25214 (NCI Thesaurus Property)
C25616 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
C3846084 (UMLS CUI-1)
C18003 (NCI Thesaurus ValueDomain)
C25688 (NCI Thesaurus ValueDomain-2)
C25717 (NCI Thesaurus Property)
C0805839 (UMLS CUI-1)
C25461 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C28554 (NCI Thesaurus Property)
C25251 (NCI Thesaurus ValueDomain-2)
C0439673 (UMLS 2011AA)
C0007465 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-2)
C28554 (NCI Thesaurus Property)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
C0005902 (UMLS CUI-1)
C25712 (NCI Thesaurus ValueDomain)
C25157 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0450442 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1521801 (UMLS CUI-2)
C25382 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass-2)
C25256 (NCI Thesaurus Property)
C25488 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ValueDomain-2)
C0678766 (UMLS CUI-1)
C0278329 (UMLS CUI-2)
C0678766 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C1521801 (UMLS CUI-2)
C25375 (NCI Thesaurus Property-2)
C25431 (NCI Thesaurus Property-3)
C25256 (NCI Thesaurus Property-4)
C25488 (NCI Thesaurus ValueDomain)
C0450442 (UMLS CUI-1)
C25639 (NCI Thesaurus Property)
C0439228 (UMLS CUI-2)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS CUI-3)
C1708 (NCI Thesaurus ObjectClass)
C2986497 (UMLS CUI-1)
C25379 (NCI Thesaurus Property)
C25488 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C3259162 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C0030705 (NCI Metathesaurus ObjectClass)
C0566251 (UMLS CUI-1)
C25594 (NCI Thesaurus Property)
C1299369 (UMLS CUI-2)
C25488 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0600688 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C1707811 (UMLS CUI-1)
C25488 (NCI Thesaurus ObjectClass)
C3840932 (UMLS CUI-2)
C25572 (NCI Thesaurus Property)
C1518384 (UMLS CUI-1)
C16212 (NCI Thesaurus ObjectClass-2)
C0087111 (UMLS CUI-2)
C25320 (NCI Thesaurus Property)
C49236 (NCI Thesaurus Property-2)
C25456 (NCI Thesaurus Property-3)
C25382 (NCI Thesaurus Property-4)
C38148 (NCI Thesaurus ValueDomain)