ID
6682
Beschrijving
NSABP PROTOCOL B-39: ADVERSE EVENT FORM FOR RADIATION THERAPY Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6F7DDC5-C879-6CDA-E034-0003BA3F9857
Link
Trefwoorden
Versies (3)
- 26-08-12 26-08-12 -
- 08-01-15 08-01-15 - Martin Dugas
- 08-06-15 08-06-15 -
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8 januari 2015
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00103181 Toxicity - NSABP PROTOCOL B-39: ADVERSE EVENT FORM FOR RADIATION THERAPY - 2295182v3.0
This paper worksheet may be completed to facilitate the entry of the adverse event information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For Protocol B-39, Form AE collects only adverse events that are possibly, probably, or definitely related to whole breast irradiation (WBI) or partial breast irradiation (PBI), regardless of whether these adverse events are expected or unexpected. Do not report adverse events resulting from chemotherapy, hormonal therapy or any other systemic cancer therapy. Complete Form AE at the end of each Reporting Period, as defined below. The Reporting Period Start Date should not lapse or overlap with the Reporting Period End Date of the prior Form AE. If the patient has a breast cancer recurrence or second primary cancer, please use the date of the cancer event as the reporting period end date. No additional AE forms will be required for this patient. If patient did not start RT, do not submit Form AE. If patient started radiation therapy (RT), use Form AE to report adverse events that are POSSIBLY, PROBABLY, or DEFINITELY RELATED to radiation therapy.
Beschrijving
Unnamed2
Beschrijving
Institution Name
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C1301943
- NCI Thesaurus ObjectClass
- C21541
- NCI Thesaurus ValueDomain-2
- C21541
- NCI Thesaurus Property
- C25364
Beschrijving
Affiliate Name
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C21541
- UMLS CUI-1
- C1510825
- NCI Thesaurus ObjectClass-2
- C25413
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25191
- NCI Thesaurus ValueDomain-2
- C21541
Beschrijving
Person Completing Form
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C1550483
- NCI Thesaurus ObjectClass
- C25657
- NCI Thesaurus Property
- C25364
Beschrijving
Data amended
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- NCI Thesaurus Property
- C25416
Beschrijving
Unnamed3
Beschrijving
Unnamed4
Beschrijving
Reporting Period Start Date
Datatype
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25616
- UMLS CUI-1
- C2361257
- NCI Thesaurus Property-2
- C25651
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25431
Beschrijving
CommonTerminologyCriteriaforAdverseEventsVersion4.0LowLevelTermName
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C49704
- UMLS 2011AA Property
- C1516728
- NCI Thesaurus Property-2
- C45559
- UMLS 2011AA Property-2
- C1705313
- NCI Thesaurus ValueDomain
- C45255
- UMLS 2011AA ValueDomain
- C1708523
- NCI Thesaurus ValueDomain-2
- C49704
- UMLS 2011AA ValueDomain-2
- C1516728
- NCI Thesaurus ValueDomain-3
- C42614
- UMLS 2011AA ValueDomain-3
- C0027365
- NCI Thesaurus ValueDomain-4
- C45559
- UMLS 2011AA ValueDomain-4
- C1705313
- NCI Thesaurus ValueDomain-5
- C25714
- UMLS 2011AA ValueDomain-5
- C0333052
Beschrijving
Reporting Period End Date
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2361259
- NCI Thesaurus Property
- C25616
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property-2
- C25651
Beschrijving
AdverseEventSeverityGrade
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C48309
- UMLS 2011AA Property
- C0441800
- NCI Thesaurus Property-2
- C49705
- UMLS 2011AA Property-2
- C1710065
- NCI Thesaurus Property-3
- C25676
- UMLS 2011AA Property-3
- C0439793
- NCI Thesaurus ValueDomain
- C41331
- UMLS 2011AA ValueDomain
- C0877248
- NCI Thesaurus ValueDomain-2
- C48309
- UMLS 2011AA ValueDomain-2
- C0441800
- NCI Thesaurus ValueDomain-3
- C25676
- UMLS 2011AA ValueDomain-3
- C0439793
Beschrijving
PatientHospitalizationInd-2
Datatype
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25179
- UMLS 2011AA Property
- C0019993
Beschrijving
Ii. Infections
Beschrijving
CommonTerminologyCriteriaforAdverseEventsVersion4.0LowLevelTermName
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C49704
- UMLS 2011AA Property
- C1516728
- NCI Thesaurus Property-2
- C45559
- UMLS 2011AA Property-2
- C1705313
- NCI Thesaurus ValueDomain
- C45255
- UMLS 2011AA ValueDomain
- C1708523
- NCI Thesaurus ValueDomain-2
- C49704
- UMLS 2011AA ValueDomain-2
- C1516728
- NCI Thesaurus ValueDomain-3
- C42614
- UMLS 2011AA ValueDomain-3
- C0027365
- NCI Thesaurus ValueDomain-4
- C45559
- UMLS 2011AA ValueDomain-4
- C1705313
- NCI Thesaurus ValueDomain-5
- C25714
- UMLS 2011AA ValueDomain-5
- C0333052
Beschrijving
AdverseEventSeverityGrade
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C48309
- UMLS 2011AA Property
- C0441800
- NCI Thesaurus Property-2
- C49705
- UMLS 2011AA Property-2
- C1710065
- NCI Thesaurus Property-3
- C25676
- UMLS 2011AA Property-3
- C0439793
- NCI Thesaurus ValueDomain
- C41331
- UMLS 2011AA ValueDomain
- C0877248
- NCI Thesaurus ValueDomain-2
- C48309
- UMLS 2011AA ValueDomain-2
- C0441800
- NCI Thesaurus ValueDomain-3
- C25676
- UMLS 2011AA ValueDomain-3
- C0439793
Beschrijving
Comments
Similar models
This paper worksheet may be completed to facilitate the entry of the adverse event information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For Protocol B-39, Form AE collects only adverse events that are possibly, probably, or definitely related to whole breast irradiation (WBI) or partial breast irradiation (PBI), regardless of whether these adverse events are expected or unexpected. Do not report adverse events resulting from chemotherapy, hormonal therapy or any other systemic cancer therapy. Complete Form AE at the end of each Reporting Period, as defined below. The Reporting Period Start Date should not lapse or overlap with the Reporting Period End Date of the prior Form AE. If the patient has a breast cancer recurrence or second primary cancer, please use the date of the cancer event as the reporting period end date. No additional AE forms will be required for this patient. If patient did not start RT, do not submit Form AE. If patient started radiation therapy (RT), use Form AE to report adverse events that are POSSIBLY, PROBABLY, or DEFINITELY RELATED to radiation therapy.
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C2347804 (UMLS CUI-1)
C25214 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus ObjectClass-2)
C0205448 (UMLS 2011AA)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0877248 (UMLS 2011AA ObjectClass)
C49704 (NCI Thesaurus Property)
C1516728 (UMLS 2011AA Property)
C45559 (NCI Thesaurus Property-2)
C1705313 (UMLS 2011AA Property-2)
C45255 (NCI Thesaurus ValueDomain)
C1708523 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ValueDomain-2)
C1516728 (UMLS 2011AA ValueDomain-2)
C42614 (NCI Thesaurus ValueDomain-3)
C0027365 (UMLS 2011AA ValueDomain-3)
C45559 (NCI Thesaurus ValueDomain-4)
C1705313 (UMLS 2011AA ValueDomain-4)
C25714 (NCI Thesaurus ValueDomain-5)
C0333052 (UMLS 2011AA ValueDomain-5)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C0877248 (UMLS 2011AA ObjectClass)
C48309 (NCI Thesaurus Property)
C0441800 (UMLS 2011AA Property)
C49705 (NCI Thesaurus Property-2)
C1710065 (UMLS 2011AA Property-2)
C25676 (NCI Thesaurus Property-3)
C0439793 (UMLS 2011AA Property-3)
C41331 (NCI Thesaurus ValueDomain)
C0877248 (UMLS 2011AA ValueDomain)
C48309 (NCI Thesaurus ValueDomain-2)
C0441800 (UMLS 2011AA ValueDomain-2)
C25676 (NCI Thesaurus ValueDomain-3)
C0439793 (UMLS 2011AA ValueDomain-3)
C1513302 (UMLS 2011AA)
C1513374 (UMLS 2011AA)
C2919019 (UMLS 2011AA)
C1517874 (UMLS 2011AA)
C1705232 (UMLS 2011AA)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25179 (NCI Thesaurus Property)
C0019993 (UMLS 2011AA Property)
C0877248 (UMLS 2011AA ObjectClass)
C49704 (NCI Thesaurus Property)
C1516728 (UMLS 2011AA Property)
C45559 (NCI Thesaurus Property-2)
C1705313 (UMLS 2011AA Property-2)
C45255 (NCI Thesaurus ValueDomain)
C1708523 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ValueDomain-2)
C1516728 (UMLS 2011AA ValueDomain-2)
C42614 (NCI Thesaurus ValueDomain-3)
C0027365 (UMLS 2011AA ValueDomain-3)
C45559 (NCI Thesaurus ValueDomain-4)
C1705313 (UMLS 2011AA ValueDomain-4)
C25714 (NCI Thesaurus ValueDomain-5)
C0333052 (UMLS 2011AA ValueDomain-5)
C0877248 (UMLS 2011AA ObjectClass)
C48309 (NCI Thesaurus Property)
C0441800 (UMLS 2011AA Property)
C49705 (NCI Thesaurus Property-2)
C1710065 (UMLS 2011AA Property-2)
C25676 (NCI Thesaurus Property-3)
C0439793 (UMLS 2011AA Property-3)
C41331 (NCI Thesaurus ValueDomain)
C0877248 (UMLS 2011AA ValueDomain)
C48309 (NCI Thesaurus ValueDomain-2)
C0441800 (UMLS 2011AA ValueDomain-2)
C25676 (NCI Thesaurus ValueDomain-3)
C0439793 (UMLS 2011AA ValueDomain-3)
C1513302 (UMLS 2011AA)
C1513374 (UMLS 2011AA)
C2919019 (UMLS 2011AA)
C1517874 (UMLS 2011AA)
C1705232 (UMLS 2011AA)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)