ID

6875

Beschrijving

Upper Gastrointestinal Cancers - Treatment Form (for Periodic Reporting) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B2-3FA4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B2-3FA4-E034-080020C9C0E0

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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Treatment - Upper Gastrointestinal Cancers - Treatment Form (for Periodic Reporting) - 2020209v2.31

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Form (for Periodic Reporting)
    1. No Instruction available.
Crf Header
Beschrijving

Crf Header

Coordinating Group Protocol Number
Beschrijving

CoordinatingGroupProtocolNumber

Datatype

text

Coordinating Group Code
Beschrijving

CoordinatingGroupCode

Datatype

text

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

Protocol Title

Datatype

text

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

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Study ID, Participating Group
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Affiliate Name
Beschrijving

AffiliateName

Datatype

text

Patient Name, Last
Beschrijving

PatientName,Last

Datatype

text

Patient Name, First
Beschrijving

PatientName,First

Datatype

text

Patient Name, Middle
Beschrijving

PatientName,Middle

Datatype

text

Gi: Treatment Reporting Interval
Beschrijving

Gi: Treatment Reporting Interval

Interval Report From Date
Beschrijving

IntervalReportFromDate

Datatype

date

Interval Report To Date
Beschrijving

IntervalReportToDate

Datatype

date

Gi: Treatment Schedule - Radiation Therapy
Beschrijving

Gi: Treatment Schedule - Radiation Therapy

Protocol Treatment, RT Ind
Beschrijving

ProtocolTreatment,RTInd

Datatype

text

RT Begin Date
Beschrijving

RTBeginDate

Datatype

date

RT End Date
Beschrijving

RTEndDate

Datatype

date

RT Type
Beschrijving

RTType

Datatype

text

RT Type, Other
Beschrijving

RTType,Other

Datatype

text

RT Site
Beschrijving

RTSite

Datatype

text

RT Total Dose
Beschrijving

RTTotalDose

Datatype

float

RT Interruptions Ind
Beschrijving

RTInterruptionsInd

Datatype

text

RT Interruptions Reason
Beschrijving

RTInterruptionsReason

Datatype

text

Gi: Treatment Cycle Information - Systemic Therapy
Beschrijving

Gi: Treatment Cycle Information - Systemic Therapy

Protocol Treatment, Systemic Therapy Ind
Beschrijving

ProtocolTreatment,SystemicTherapyInd

Datatype

text

Total Course Number
Beschrijving

TotalCourseNumber

Datatype

float

First Treatment Start Date
Beschrijving

FirstTreatmentStartDate

Datatype

date

Last Treatment Date
Beschrijving

LastTreatmentDate

Datatype

date

Systemic Therapy Type
Beschrijving

SystemicTherapyType

Datatype

text

Systemic Therapy Type, Other
Beschrijving

SystemicTherapyType,Other

Datatype

text

Agent Name
Beschrijving

AgentName

Datatype

text

Agent Total Dose (per course)
Beschrijving

AgentTotalDose(percourse)

Datatype

float

Agent Dose Units
Beschrijving

AgentDoseUnits

Datatype

text

Dose Modification (Change)
Beschrijving

DoseModification(Change)

Datatype

text

Therapy Modification Name
Beschrijving

TherapyModificationName

Datatype

text

Therapy Modification Reason
Beschrijving

TherapyModificationReason

Datatype

text

Allows Documentation Of Any Additional Cooments
Beschrijving

Allows Documentation Of Any Additional Cooments

Comments
Beschrijving

Comments

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Form (for Periodic Reporting)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
Item
Participating Group Code
text
CL.1
Code List
Participating Group Code
CL Item
Http://ctep.info.nih.gov. (http://ctep.info.nih.gov.)
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
Gi: Treatment Reporting Interval
IntervalReportFromDate
Item
Interval Report From Date
date
IntervalReportToDate
Item
Interval Report To Date
date
Item Group
Gi: Treatment Schedule - Radiation Therapy
Item
Protocol Treatment, RT Ind
text
CL.2
Code List
Protocol Treatment, RT Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
RTBeginDate
Item
RT Begin Date
date
RTEndDate
Item
RT End Date
date
Item
RT Type
text
CL.3
Code List
RT Type
CL Item
Adjuvant Radiation Therapy (Adjuvant RT)
CL Item
Brachytherapy (Brachytherapy)
CL054378 (NCI Metathesaurus)
CL Item
Palliative Radiation Therapy (Palliative RT)
CL Item
Neoadjuvant Radiation Therapy (Neoadjuvant RT)
CL Item
Other, Specify (Other, specify)
CL Item
External Beam Radiation (External beam radiation)
RTType,Other
Item
RT Type, Other
text
RTSite
Item
RT Site
text
RTTotalDose
Item
RT Total Dose
float
Item
RT Interruptions Ind
text
CL.4
Code List
RT Interruptions Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, For Other Reasons, Specify (Yes, for other reasons, specify)
CL Item
Yes, Due To Toxicity (Yes, due to toxicity)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
RTInterruptionsReason
Item
RT Interruptions Reason
text
Item Group
Gi: Treatment Cycle Information - Systemic Therapy
Item
Protocol Treatment, Systemic Therapy Ind
text
CL.5
Code List
Protocol Treatment, Systemic Therapy Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
TotalCourseNumber
Item
Total Course Number
float
FirstTreatmentStartDate
Item
First Treatment Start Date
date
LastTreatmentDate
Item
Last Treatment Date
date
Item
Systemic Therapy Type
text
CL.6
Code List
Systemic Therapy Type
CL Item
Chemotherapy (Chemotherapy)
C15632 (NCI Thesaurus)
C0392920 (UMLS 2011AA)
CL Item
Other Specify (Other, specify)
CL Item
Immunotherapy (Immunotherapy)
C15262 (NCI Thesaurus)
C0021083 (UMLS 2011AA)
SystemicTherapyType,Other
Item
Systemic Therapy Type, Other
text
AgentName
Item
Agent Name
text
AgentTotalDose(percourse)
Item
Agent Total Dose (per course)
float
Item
Agent Dose Units
text
CL.7
Code List
Agent Dose Units
CL Item
Curie (Ci)
C0700085 (NCI Metathesaurus)
CL Item
Unit (unit)
C44278 (NCI Thesaurus)
C0439148 (UMLS 2011AA)
CL Item
Hertz (Hz)
CL Item
International Unit (IU)
C28255 (NCI Thesaurus)
CL Item
Joules Per Centimeter Square (JCM2)
CL Item
Liter (L)
CL Item
Megahertz (MHz)
CL Item
Milligrams Per Milliliter Per Minute (MMM)
CL Item
Million Electron Volts (MeV)
CL Item
Megarad (Mrad)
CL Item
Not Applicable (N/A)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Osmole (Osmol)
CL Item
Pascal (Pa)
C42547 (NCI Thesaurus)
C0439473 (UMLS 2011AA)
CL Item
Viral Particles (VP)
CL Item
Centimeter (cm)
C49668 (NCI Thesaurus)
C0475210 (UMLS 2011AA)
CL Item
Deciliter (dL)
CL Item
Decimeter (dm)
CL Item
Gram (g)
C0439208 (NCI Metathesaurus)
CL Item
Gravity (in Centrifugation) (gravity)
CL Item
Kilohertz (kHz)
CL Item
Kilopascal (kPa)
CL Item
Kilo-electron Volt (keV)
CL Item
Kilogram (kg)
C28252 (NCI Thesaurus)
C0439209 (UMLS 2011AA)
CL Item
Meter (m)
C0475209 (NCI Metathesaurus)
CL Item
Millicurie (mCi)
CL Item
Milliequivalent (mEq)
CL Item
Milliliter (mL)
C28254 (NCI Thesaurus)
C0439242 (UMLS 2011AA)
CL Item
Milliosmole (mOsmol)
CL Item
Million Unit (mU)
CL Item
Millivolt (mV)
C0456691 (NCI Metathesaurus)
CL Item
Microcurie (mcCi)
CL Item
Microliter (mcL)
CL Item
Microgram (mcg)
CL Item
Micrometer (mcm)
CL Item
Milligram (mg)
C28253 (NCI Thesaurus)
C0439210 (UMLS 2011AA)
CL Item
Milliunit (milliunit)
CL Item
Millimeter (mm)
C28251 (NCI Thesaurus)
C0439200 (UMLS 2011AA)
CL Item
Millimole (mmol)
CL Item
Gram-molecular Weight (mole) (mol)
CL Item
Nanocurie (nCi)
C0560007 (NCI Metathesaurus)
CL Item
Nanogram (ng)
CL Item
Nanometer (nm)
C0439202 (NCI Metathesaurus)
CL Item
Nanometers Of Light (nm light)
CL Item
Plaque Forming Unit (pfu)
CL Item
Picogram (pg)
C0439213 (NCI Metathesaurus)
CL Item
Pounds Per Square Inch (psi)
C0439472 (NCI Metathesaurus)
CL Item
Gram-equivalent Weight (Eq)
Item
Dose Modification (Change)
text
CL.8
Code List
Dose Modification (Change)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
TherapyModificationName
Item
Therapy Modification Name
text
TherapyModificationReason
Item
Therapy Modification Reason
text
Item Group
Allows Documentation Of Any Additional Cooments
Comments
Item
Comments
text
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