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ID

6919

Description

Gynecologic Cancer - Toxicity Form- copy 2 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=13996779-2A06-0B29-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=13996779-2A06-0B29-E044-0003BA3F9857

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Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
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January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Toxicity - Gynecologic Cancer - Toxicity Form- copy 2 - 2481262v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Gynecologic Cancer - Toxicity Form- copy 2
      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

    Gyn: Form Administration
    Description

    Gyn: Form Administration

    Person Completing Form, First Name
    Description

    PersonCompletingForm,FirstName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Amended Data Ind
    Description

    AmendedDataInd

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Interval Report From Date
    Description

    IntervalReportFromDate

    Data type

    date

    Interval Report To Date
    Description

    IntervalReportToDate

    Data type

    date

    Responsible Person Last Name
    Description

    Person Completing Form Last Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass-2
    C25657
    UMLS CUI-2
    C1301584
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25191
    Responsible Person Last Name
    Description

    Person Completing Form Last Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass-2
    C25657
    UMLS CUI-2
    C1301584
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25191
    Responsible Person Last Name
    Description

    ResponsiblePersonLastName

    Data type

    text

    Gyn: Adverse Events
    Description

    Gyn: Adverse Events

    CTC Adverse Event Report Begin Date
    Description

    CTCAdverseEventReportBeginDate

    Data type

    date

    CTC Adverse Event Report End Date
    Description

    CTCAdverseEventReportEndDate

    Data type

    date

    CTC Adverse Event Term
    Description

    CTCAdverseEventTerm

    Data type

    text

    CTC Adverse Event Grade
    Description

    CTCAdverseEventGrade

    Data type

    text

    CTC Adverse Event Attribution Code
    Description

    CTCAdverseEventAttributionCode

    Data type

    text

    CTC Adverse Event Term, Other
    Description

    CTCAdverseEventTerm,Other

    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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    1 forms
    1. StudyEvent: Gynecologic Cancer - Toxicity Form- copy 2
      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
    Gyn: Form Administration
    PersonCompletingForm,FirstName
    Item
    Person Completing Form, First Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Item
    Amended Data Ind
    text
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    CL.1
    Code List
    Amended Data 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)
    IntervalReportFromDate
    Item
    Interval Report From Date
    date
    IntervalReportToDate
    Item
    Interval Report To Date
    date
    Person Completing Form Last Name
    Item
    Responsible Person Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass-2)
    C1301584 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    Person Completing Form Last Name
    Item
    Responsible Person Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass-2)
    C1301584 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    ResponsiblePersonLastName
    Item
    Responsible Person Last Name
    text
    Item Group
    Gyn: Adverse Events
    CTCAdverseEventReportBeginDate
    Item
    CTC Adverse Event Report Begin Date
    date
    CTCAdverseEventReportEndDate
    Item
    CTC Adverse Event Report End Date
    date
    Item
    CTC Adverse Event Term
    text
    CL.2
    Code List
    CTC Adverse Event Term
    CL Item
    Ctep.info.nih.gov/ctc3/ctc.htm (http://ctep.info.nih.gov/CTC3/ctc.htm)
    Item
    CTC Adverse Event Grade
    text
    CL.3
    Code List
    CTC Adverse Event Grade
    CL Item
    Ctep.info.nih.gov/ctc3/ctc.htm (http://ctep.info.nih.gov/CTC3/ctc.htm)
    Item
    CTC Adverse Event Attribution Code
    text
    CL.4
    Code List
    CTC Adverse Event Attribution Code
    CL Item
    Definitely (Definitely)
    CL Item
    Possibly (Possibly)
    CL Item
    Unrelated (Unrelated)
    C25328 (NCI Thesaurus)
    C0445356 (UMLS 2011AA)
    CL Item
    Unlikely (Unlikely)
    CL Item
    Probably (Probably)
    CTCAdverseEventTerm,Other
    Item
    CTC Adverse Event Term, Other
    text
    Item Group
    Allows Documentation Of Any Additional Cooments
    Comments
    Item
    Comments
    text
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