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ID

6579

Description

Z1041: End of Intervention Period Form Combination Chemotherapy and Paclitaxel Plus Trastuzumab in Treating Women With Palpable Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211D4CFE-8742-4C95-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211D4CFE-8742-4C95-E044-0003BA3F9857

Mots-clés

  1. 26/08/2012 26/08/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
Téléchargé le

8 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy

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    Breast Cancer NCT00513292 Treatment - Z1041: End of Intervention Period Form - 2533589v1.0

    No Instruction available.

    1. StudyEvent: Z1041: End of Intervention Period Form
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Visit
    Description

    AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C19712
    UMLS 2011AA ObjectClass
    C1515944
    NCI Thesaurus ObjectClass-2
    C25716
    UMLS 2011AA ObjectClass-2
    C0545082
    Date
    Description

    PatientNotScheduleVisitDate

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus Property-2
    C25211
    UMLS 2011AA Property-2
    C0086960
    NCI Thesaurus Property-3
    C25716
    UMLS 2011AA Property-3
    C0545082
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Patient ID (Patient ID issued during registration or previously issued Patient ID.)
    Description

    Patient Study ID

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Patient Initials (F M L)
    Description

    Patient Initials

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution No.
    Description

    Institution Number

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Institution Name
    Description

    Institution Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Header
    Description

    Header

    Reason Treatment Ended (Mark "X" in only one box)
    Description

    Off Treatment Reason

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C1518544
    NCI Thesaurus ObjectClass
    C25601
    UMLS CUI-2
    C0566251
    NCI Thesaurus Property
    C25365
    Other, specify
    Description

    Off Treatment Reason, specify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C1518544
    NCI Thesaurus ObjectClass
    C25601
    UMLS CUI-2
    C0566251
    NCI Thesaurus Property
    C25365
    UMLS CUI-3
    C1521902
    If death, mark type
    Description

    PatientHeartDiseasesandDisordersDeathType

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C28554
    UMLS 2011AA Property
    C0011065
    NCI Thesaurus Property-2
    C12727
    UMLS 2011AA Property-2
    C0018787
    NCI Thesaurus Property-3
    C2991
    UMLS 2011AA Property-3
    C0012634
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Other specify
    Description

    DeathProtocolTreatmentRelatedSpecify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25320
    UMLS 2011AA Property
    C1507394
    NCI Thesaurus ObjectClass
    C28554
    UMLS 2011AA ObjectClass
    C0011065
    NCI Thesaurus Property-2
    C15368
    Treatment End Date (Intervention)
    Description

    Treatment End Date

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1531784
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25275
    NCI Thesaurus Property-2
    C25496
    Footer Module
    Description

    Footer Module

    Completed by
    Description

    Person Completing Form

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Date Form Completed
    Description

    Date Form Completed

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1115437
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    NCI Thesaurus ValueDomain-2
    C25367

    Similar models

    No Instruction available.

    1. StudyEvent: Z1041: End of Intervention Period Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header Module
    Item
    Visit
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C19712 (NCI Thesaurus ObjectClass)
    C1515944 (UMLS 2011AA ObjectClass)
    C25716 (NCI Thesaurus ObjectClass-2)
    C0545082 (UMLS 2011AA ObjectClass-2)
    Code List
    Visit
    CL Item
    Surgery (Surgery)
    CL Item
    Unscheduled (Unscheduled)
    PatientNotScheduleVisitDate
    Item
    Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C25211 (NCI Thesaurus Property-2)
    C0086960 (UMLS 2011AA Property-2)
    C25716 (NCI Thesaurus Property-3)
    C0545082 (UMLS 2011AA Property-3)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Patient Study ID
    Item
    Patient ID (Patient ID issued during registration or previously issued Patient ID.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Patient Initials
    Item
    Patient Initials (F M L)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Institution Name
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Item Group
    Header
    Item
    Reason Treatment Ended (Mark "X" in only one box)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    Code List
    Reason Treatment Ended (Mark "X" in only one box)
    CL Item
    Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
    CL Item
    Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
    CL Item
    Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)
    CL Item
    Alternative Therapy (Alternative therapy)
    CL Item
    Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
    CL Item
    Death On Study (Death on study)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Off Treatment Reason, specify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    C1521902 (UMLS CUI-3)
    Item
    If death, mark type
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28554 (NCI Thesaurus Property)
    C0011065 (UMLS 2011AA Property)
    C12727 (NCI Thesaurus Property-2)
    C0018787 (UMLS 2011AA Property-2)
    C2991 (NCI Thesaurus Property-3)
    C0012634 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    If death, mark type
    CL Item
    Definite Cardiac (Definite cardiac)
    CL Item
    Probable Cardiac (Probable cardiac)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    DeathProtocolTreatmentRelatedSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus Property)
    C1507394 (UMLS 2011AA Property)
    C28554 (NCI Thesaurus ObjectClass)
    C0011065 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus Property-2)
    Treatment End Date
    Item
    Treatment End Date (Intervention)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1531784 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    Item Group
    Footer Module
    Person Completing Form
    Item
    Completed by
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Date Form Completed
    Item
    Date Form Completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1115437 (UMLS CUI-1)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)

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