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ID

6636

Beschrijving

AMC-063 Off-Protocol Treatment Summary Form (F05) Bortezomib in Treating Patients With Relapsed or Refractory AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8100CE37-23B4-8765-E040-BB89AD431777

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8100CE37-23B4-8765-E040-BB89AD431777

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 08-01-15 08-01-15 - Martin Dugas
Geüploaded op

8 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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    Sarcoma NCT01016730 Off Treatment - AMC-063 Off-Protocol Treatment Summary Form (F05) - 3019646v1.0

    Engels

    Please submit this form if the subject has completed study treatment or discontinued study treatment prematurely. Note: Submission of this form DOES NOT mean the subject is necessarily off study. Please check the protocol for any post treatment follow-up requirements

    1 Formulieren  
    Ccrr Module For Off Protocol Treatment Summary - Rf05b
    Beschrijving

    Ccrr Module For Off Protocol Treatment Summary - Rf05b

    Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
    Beschrijving

    Treatment End Date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C1531784 (Date treatment stopped)
    SNOMED
    413947000
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus Property
    C25275 (undefined)
    NCI Thesaurus Property-2
    C25496 (undefined)
    Reason Treatment Ended (select the primary reason)
    Beschrijving

    Off Treatment Reason

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS CUI-1
    C1518544 (Off Treatment)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS CUI-2
    C0566251 (Reason and justification)
    SNOMED
    288830005
    NCI Thesaurus Property
    C25365 (undefined)
    Other, specify
    Beschrijving

    Off Treatment Reason, specify

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C1518544 (Off Treatment)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS CUI-2
    C0566251 (Reason and justification)
    SNOMED
    288830005
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS CUI-3
    C1521902 (To specify)
    Comments
    Beschrijving

    Research Comments

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS CUI-1
    C0947611 (Comment)
    LOINC
    LP72293-1
    NCI Thesaurus ObjectClass
    C15319 (undefined)
    NCI Thesaurus Property
    C25393 (undefined)
    Terug naar het begin van de pagina

    Similar models

    Please submit this form if the subject has completed study treatment or discontinued study treatment prematurely. Note: Submission of this form DOES NOT mean the subject is necessarily off study. Please check the protocol for any post treatment follow-up requirements

    1 Formulieren
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Ccrr Module For Off Protocol Treatment Summary - Rf05b
    Treatment End Date
    Item
    Last Date (any modality of) protocol therapy was given (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1531784 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    Item
    Reason Treatment Ended (select the primary reason)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    CL.1
    Code List
    Reason Treatment Ended (select the primary reason)
    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
    Death On Study (Death on study)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)
    CL Item
    Patient Withdrawal Or Refusal Before Beginning Protocol Therapy (Patient withdrawal/refusal prior to 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
    Lost To Follow-up (Lost to follow-up)
    CL310949 (NCI Metathesaurus)
    CL Item
    Cytogenetic Resistance (Cytogenetic Resistance)
    CL Item
    Disease Progression Before Active Treatment (Disease Progression before active treatment)
    CL Item
    No Treatment, Per Protocol Criteria (No treatment, per protocol criteria)
    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)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Terug naar het begin van de pagina 

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