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ID

6864

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-08 2015-01-08 - Martin Dugas
Uppladdad den

8 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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    Follow-Up - Melanoma-Follow-up Form - 2020198v2.31

    No Instruction available.

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

    Crf Header

    Coordinating Group Protocol Number
    Beskrivning

    CoordinatingGroupProtocolNumber

    Datatyp

    text

    Coordinating Group Code
    Beskrivning

    CoordinatingGroupCode

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    Protocol Title
    Beskrivning

    Protocol Title

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-1
    C2986303 (Study Protocol Document Version Public Title)
    NCI Thesaurus Property
    C42774 (undefined)
    Patient Study ID, Coordinating Group
    Beskrivning

    PatientStudyID,CoordinatingGroup

    Datatyp

    text

    Patient Study ID, Participating Group
    Beskrivning

    PatientStudyID,ParticipatingGroup

    Datatyp

    text

    Participating Group Code
    Beskrivning

    ParticipatingGroupCode

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    Institution Name
    Beskrivning

    InstitutionName

    Datatyp

    text

    Affiliate Name
    Beskrivning

    AffiliateName

    Datatyp

    text

    Patient Name, Last
    Beskrivning

    PatientName,Last

    Datatyp

    text

    Patient Name, First
    Beskrivning

    PatientName,First

    Datatyp

    text

    Patient Name, Middle
    Beskrivning

    PatientName,Middle

    Datatyp

    text

    Melanoma: Vital Status
    Beskrivning

    Melanoma: Vital Status

    Patient's Vital Status
    Beskrivning

    Patient'sVitalStatus

    Datatyp

    text

    Death Reason
    Beskrivning

    DeathReason

    Datatyp

    text

    Death Reason, Specify
    Beskrivning

    DeathReason,Specify

    Datatyp

    text

    Death Date/Last Contact Date
    Beskrivning

    DeathDate/LastContactDate

    Datatyp

    date

    Melanoma: Disease Follow-up Status
    Beskrivning

    Melanoma: Disease Follow-up Status

    Cancer Follow-up Status Ind
    Beskrivning

    CancerFollow-upStatusInd

    Datatyp

    text

    Cancer Follow-up Status Date
    Beskrivning

    CancerFollow-upStatusDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991 (undefined)
    UMLS 2011AA ObjectClass
    C0012634 (Disease)
    SNOMED
    64572001
    LOINC
    LP21006-9
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS 2011AA Property
    C0678257 (Description)
    LOINC
    LP6800-9
    Melanoma: Notice Of Progression
    Beskrivning

    Melanoma: Notice Of Progression

    Progression Ind
    Beskrivning

    ProgressionInd

    Datatyp

    text

    Progression Date
    Beskrivning

    ProgressionDate

    Datatyp

    date

    Progression Site
    Beskrivning

    ProgressionSite

    Datatyp

    text

    Progression Site, Other Visceral
    Beskrivning

    ProgressionSite,OtherVisceral

    Datatyp

    text

    Progression Site, Other Non-visceral
    Beskrivning

    ProgressionSite,OtherNon-visceral

    Datatyp

    text

    RT Recurrence Site Ind
    Beskrivning

    RTRecurrenceSiteInd

    Datatyp

    boolean

    Melanoma: Non-protocol Therapy
    Beskrivning

    Melanoma: Non-protocol Therapy

    Non-Protocol Therapy Ind
    Beskrivning

    Non-ProtocolTherapyInd

    Datatyp

    text

    Other Therapy Type
    Beskrivning

    OtherTherapyType

    Datatyp

    text

    Non-Protocol Therapy Date, First
    Beskrivning

    Non-ProtocolTherapyDate,First

    Datatyp

    date

    Melanoma: Notice Of New Primary
    Beskrivning

    Melanoma: Notice Of New Primary

    New Primary Cancer Ind
    Beskrivning

    NewPrimaryCancerInd

    Datatyp

    text

    New Primary Cancer Date
    Beskrivning

    NewPrimaryCancerDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    New Primary Site
    Beskrivning

    NewPrimarySite

    Datatyp

    text

    Melanoma: Long-term Toxicity
    Beskrivning

    Melanoma: Long-term Toxicity

    Late Adverse Event Ind
    Beskrivning

    LateAdverseEventInd

    Datatyp

    text

    Late Adverse Event Term
    Beskrivning

    LateAdverseEventTerm

    Datatyp

    text

    Late Adverse Event Grade
    Beskrivning

    LateAdverseEventGrade

    Datatyp

    text

    Allows Documentation Of Any Additional Cooments
    Beskrivning

    Allows Documentation Of Any Additional Cooments

    Comments
    Beskrivning

    Comments

    Datatyp

    text

    Similar models

    No Instruction available.

    1. StudyEvent: Melanoma-Follow-up Form
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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
    Code List
    Patient's Vital Status
    CL Item
    Dead (Dead)
    CL Item
    Alive (Alive)
    Item
    Death Reason
    text
    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
    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
    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
    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
    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
    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
    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
    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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