ID

6864

Description

Melanoma-Follow-up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A99C-3FA4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A99C-3FA4-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
Uploaded on

January 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Melanoma-Follow-up Form - 2020198v2.31

English

No Instruction available.

1 forms  
  1. StudyEvent: Melanoma-Follow-up Form
    1. No Instruction available.
Crf Header
Description

Crf Header

Coordinating Group Protocol Number
Description

CoordinatingGroupProtocolNumber

Data type

text

Coordinating Group Code
Description

CoordinatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Study ID, Participating Group
Description

PatientStudyID,ParticipatingGroup

Data type

text

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Institution Name
Description

InstitutionName

Data type

text

Affiliate Name
Description

AffiliateName

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

Patient Name, Middle
Description

PatientName,Middle

Data type

text

Melanoma: Vital Status
Description

Melanoma: Vital Status

Patient's Vital Status
Description

Patient'sVitalStatus

Data type

text

Death Reason
Description

DeathReason

Data type

text

Death Reason, Specify
Description

DeathReason,Specify

Data type

text

Death Date/Last Contact Date
Description

DeathDate/LastContactDate

Data type

date

Melanoma: Disease Follow-up Status
Description

Melanoma: Disease Follow-up Status

Cancer Follow-up Status Ind
Description

CancerFollow-upStatusInd

Data type

text

Cancer Follow-up Status Date
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Melanoma: Notice Of Progression
Description

Melanoma: Notice Of Progression

Progression Ind
Description

ProgressionInd

Data type

text

Progression Date
Description

ProgressionDate

Data type

date

Progression Site
Description

ProgressionSite

Data type

text

Progression Site, Other Visceral
Description

ProgressionSite,OtherVisceral

Data type

text

Progression Site, Other Non-visceral
Description

ProgressionSite,OtherNon-visceral

Data type

text

RT Recurrence Site Ind
Description

RTRecurrenceSiteInd

Data type

boolean

Melanoma: Non-protocol Therapy
Description

Melanoma: Non-protocol Therapy

Non-Protocol Therapy Ind
Description

Non-ProtocolTherapyInd

Data type

text

Other Therapy Type
Description

OtherTherapyType

Data type

text

Non-Protocol Therapy Date, First
Description

Non-ProtocolTherapyDate,First

Data type

date

Melanoma: Notice Of New Primary
Description

Melanoma: Notice Of New Primary

New Primary Cancer Ind
Description

NewPrimaryCancerInd

Data type

text

New Primary Cancer Date
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site
Description

NewPrimarySite

Data type

text

Melanoma: Long-term Toxicity
Description

Melanoma: Long-term Toxicity

Late Adverse Event Ind
Description

LateAdverseEventInd

Data type

text

Late Adverse Event Term
Description

LateAdverseEventTerm

Data type

text

Late Adverse Event Grade
Description

LateAdverseEventGrade

Data type

text

Allows Documentation Of Any Additional Cooments
Description

Allows Documentation Of Any Additional Cooments

Comments
Description

Comments

Data type

text

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No Instruction available.

1 forms
  1. StudyEvent: Melanoma-Follow-up Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Crf Header
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientName,Middle
Item
Patient Name, Middle
text
Item Group
Melanoma: Vital Status
Item
Patient's Vital Status
text
CL.1
Code List
Patient's Vital Status
CL Item
Dead (Dead)
CL Item
Alive (Alive)
Item
Death Reason
text
CL.2
Code List
Death Reason
CL Item
Due To Other Cause, Specify (Due to other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
DeathReason,Specify
Item
Death Reason, Specify
text
DeathDate/LastContactDate
Item
Death Date/Last Contact Date
date
Item Group
Melanoma: Disease Follow-up Status
Item
Cancer Follow-up Status Ind
text
CL.3
Code List
Cancer Follow-up Status Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Cancer Follow-up Status Date
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Melanoma: Notice Of Progression
Item
Progression Ind
text
CL.4
Code List
Progression Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate
Item
Progression Date
date
Item
Progression Site
text
CL.5
Code List
Progression Site
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Brain (Brain)
C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)
CL Item
Distant Lymph Nodes (Distant lymph nodes)
CL Item
Distant Skin/subcutaneous Tissue, Including Soft Tissue Metastases (Distant skin/subcutaneous tissue)
CL Item
Intransit Recurrence (everything In Between The Local And Regional Recurrence) (Intransit recurrence)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Regional Recurrence (the Regional Lymph Nodes Or In The Regional Nodal Basin) (Regional recurrence)
CL Item
Any Local-regional Recurrence (use This Value In Place Of Local Recurrence, Regional Recurrence, And Intransit Recurrence) (Local-regional recurrence)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Other Cns (Other CNS)
CL Item
Other Non-visceral, Specify (Other non-visceral, specify)
CL Item
Other Visceral, Specify (Other visceral, specify)
CL Item
Local Recurrence (within 2 Cm Of The Primary) (Local recurrence)
ProgressionSite,OtherVisceral
Item
Progression Site, Other Visceral
text
ProgressionSite,OtherNon-visceral
Item
Progression Site, Other Non-visceral
text
RTRecurrenceSiteInd
Item
RT Recurrence Site Ind
boolean
Item Group
Melanoma: Non-protocol Therapy
Item
Non-Protocol Therapy Ind
text
CL.7
Code List
Non-Protocol Therapy Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
OtherTherapyType
Item
Other Therapy Type
text
Non-ProtocolTherapyDate,First
Item
Non-Protocol Therapy Date, First
date
Item Group
Melanoma: Notice Of New Primary
Item
New Primary Cancer Ind
text
CL.8
Code List
New Primary Cancer Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
NewPrimaryCancerDate
Item
New Primary Cancer Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site
text
Item Group
Melanoma: Long-term Toxicity
Item
Late Adverse Event Ind
text
CL.9
Code List
Late Adverse Event Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Late Adverse Event Term
text
CL.10
Code List
Late Adverse Event Term
CL Item
Use Rtog/eortc Grading System ( See Ctc Version 2.0. Http://ctep.info.nih.gov/ctc3/ctc.htm). (Use RTOG/EORTC grading system ( See CTC version 2.0. http://ctep.info.nih.gov/CTC3/ctc.htm).)
LateAdverseEventGrade
Item
Late Adverse Event Grade
text
Item Group
Allows Documentation Of Any Additional Cooments
Comments
Item
Comments
text
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