ID

6907

Beskrivning

Upper Gastrointestinal Cancers - Treatment Summary Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B4-3FA4-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B4-3FA4-E034-080020C9C0E0

Nyckelord

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

8 januari 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Treatment - Upper Gastrointestinal Cancers - Treatment Summary Form - 2020210v2.31

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary 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
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Beskrivning

Protocol Title

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
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

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

Gi: Treatment Plan
Beskrivning

Gi: Treatment Plan

Treatment Begin Date
Beskrivning

TreatmentBeginDate

Datatyp

date

Treatment End Date
Beskrivning

TreatmentEndDate

Datatyp

date

Off Treatment Reason
Beskrivning

OffTreatmentReason

Datatyp

text

Off Treatment Reason, Other
Beskrivning

OffTreatmentReason,Other

Datatyp

text

Gi: Treatment Summary - Surgery
Beskrivning

Gi: Treatment Summary - Surgery

Protocol Treatment, Surgery Ind
Beskrivning

ProtocolTreatment,SurgeryInd

Datatyp

text

Protocol Surgery Date
Beskrivning

ProtocolSurgeryDate

Datatyp

date

Protocol Surgery Type
Beskrivning

ProtocolSurgeryType

Datatyp

text

Surgical Treatment Completed
Beskrivning

SurgicalTreatmentCompleted

Datatyp

text

Surgical Treatment Modification Reason
Beskrivning

SurgicalTreatmentModificationReason

Datatyp

text

Gi: Treatment Summary - Radiation Therapy
Beskrivning

Gi: Treatment Summary - Radiation Therapy

Protocol Treatment, RT Ind
Beskrivning

ProtocolTreatment,RTInd

Datatyp

text

RT Begin Date
Beskrivning

RTBeginDate

Datatyp

date

RT End Date
Beskrivning

RTEndDate

Datatyp

date

RT Type
Beskrivning

RTType

Datatyp

text

RT Type, Other
Beskrivning

RTType,Other

Datatyp

text

RT Site
Beskrivning

RTSite

Datatyp

text

RT Interruptions Ind
Beskrivning

RTInterruptionsInd

Datatyp

text

RT Interruptions Reason
Beskrivning

RTInterruptionsReason

Datatyp

text

Gi: Treatment Summary - Systemic Therapy
Beskrivning

Gi: Treatment Summary - Systemic Therapy

Protocol Treatment, Systemic Therapy Ind
Beskrivning

ProtocolTreatment,SystemicTherapyInd

Datatyp

text

First Treatment Start Date
Beskrivning

FirstTreatmentStartDate

Datatyp

date

Last Treatment Date
Beskrivning

LastTreatmentDate

Datatyp

date

Systemic Therapy Type
Beskrivning

SystemicTherapyType

Datatyp

text

Systemic Therapy Type, Other
Beskrivning

SystemicTherapyType,Other

Datatyp

text

Agent Name
Beskrivning

AgentName

Datatyp

text

Dose Modification (Change)
Beskrivning

DoseModification(Change)

Datatyp

text

Therapy Modification Name
Beskrivning

TherapyModificationName

Datatyp

text

Therapy Modification Reason
Beskrivning

TherapyModificationReason

Datatyp

text

Tillbaka till toppen

Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary 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
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 Plan
TreatmentBeginDate
Item
Treatment Begin Date
date
TreatmentEndDate
Item
Treatment End Date
date
Item
Off Treatment Reason
text
CL.2
Code List
Off Treatment Reason
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death On Study (Death on study)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
OffTreatmentReason,Other
Item
Off Treatment Reason, Other
text
Item Group
Gi: Treatment Summary - Surgery
Item
Protocol Treatment, Surgery Ind
text
CL.3
Code List
Protocol Treatment, Surgery 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)
ProtocolSurgeryDate
Item
Protocol Surgery Date
date
ProtocolSurgeryType
Item
Protocol Surgery Type
text
Item
Surgical Treatment Completed
text
CL.4
Code List
Surgical Treatment Completed
CL Item
Yes, Surgical Treatment Was Completed As Per Protocol (Yes)
CL Item
No, Surgical Treatment Was Not Done (specify) (no, surgical treatment was not done (specify))
CL Item
No, Surgical Treatment Was Modified From Protocol Specification (specify) (no, surgical treatment was modified from protocol specification (specify))
SurgicalTreatmentModificationReason
Item
Surgical Treatment Modification Reason
text
Item Group
Gi: Treatment Summary - Radiation Therapy
Item
Protocol Treatment, RT Ind
text
CL.5
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.6
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
Item
RT Interruptions Ind
text
CL.7
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 Summary - Systemic Therapy
Item
Protocol Treatment, Systemic Therapy Ind
text
CL.8
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)
FirstTreatmentStartDate
Item
First Treatment Start Date
date
LastTreatmentDate
Item
Last Treatment Date
date
Item
Systemic Therapy Type
text
CL.9
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
Item
Dose Modification (Change)
text
CL.10
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
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial