ID

6928

Descripción

Gynecologic Cancer - Treatment by Cycle Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A96C-3FA4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A96C-3FA4-E034-080020C9C0E0

Palabras clave

Versiones (2)
  1. 20/9/12 20/9/12 -
  2. 8/1/15 8/1/15 - Martin Dugas
Subido en

8 de enero de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Treatment - Gynecologic Cancer - Treatment by Cycle Form - 2019338v2.31

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: Gynecologic Cancer - Treatment by Cycle Form
    1. No Instruction available.
Crf Header
Descripción

Crf Header

Coordinating Group Protocol Number
Descripción

CoordinatingGroupProtocolNumber

Tipo de datos

text

Coordinating Group Code
Descripción

CoordinatingGroupCode

Tipo de datos

text

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

Protocol Title

Tipo de datos

text

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

PatientStudyID,CoordinatingGroup

Tipo de datos

text

Patient Study ID, Participating Group
Descripción

PatientStudyID,ParticipatingGroup

Tipo de datos

text

Participating Group Code
Descripción

ParticipatingGroupCode

Tipo de datos

text

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

InstitutionName

Tipo de datos

text

Affiliate Name
Descripción

AffiliateName

Tipo de datos

text

Patient Name, Last
Descripción

PatientName,Last

Tipo de datos

text

Patient Name, First
Descripción

PatientName,First

Tipo de datos

text

Patient Name, Middle
Descripción

PatientName,Middle

Tipo de datos

text

Gyn: Form Administration
Descripción

Gyn: Form Administration

Person Completing Form, Last Name
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Person Completing Form, First Name
Descripción

PersonCompletingForm,FirstName

Tipo de datos

text

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

AmendedDataInd

Tipo de datos

text

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

IntervalReportFromDate

Tipo de datos

date

Interval Report To Date
Descripción

IntervalReportToDate

Tipo de datos

date

Gyn: Surgical Treatment
Descripción

Gyn: Surgical Treatment

Protocol Surgery Ind
Descripción

ProtocolSurgeryInd

Tipo de datos

text

Protocol Surgery Date
Descripción

ProtocolSurgeryDate

Tipo de datos

date

Protocol Surgery Type
Descripción

ProtocolSurgeryType

Tipo de datos

text

Protocol Surgery Other Type
Descripción

ProtocolSurgeryOtherType

Tipo de datos

text

Protocol Surgery Reason
Descripción

ProtocolSurgeryReason

Tipo de datos

text

Protocol Surgery Other Reason
Descripción

ProtocolSurgeryOtherReason

Tipo de datos

text

Residual Disease
Descripción

ResidualDisease

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Protocol Surgery, Qualifying Results Ind
Descripción

ProtocolSurgery,QualifyingResultsInd

Tipo de datos

text

Gyn: Treatment Modifications (surgical Treatment)
Descripción

Gyn: Treatment Modifications (surgical Treatment)

Dose Modification (Change)
Descripción

DoseModification(Change)

Tipo de datos

text

Dose Modification Reason
Descripción

DoseModificationReason

Tipo de datos

text

Gyn: Radiation Therapy-treatment Cycle Information
Descripción

Gyn: Radiation Therapy-treatment Cycle Information

RT Type
Descripción

RTType

Tipo de datos

text

RT Other Type
Descripción

RTOtherType

Tipo de datos

text

Brachytherapy Application Method
Descripción

BrachytherapyApplicationMethod

Tipo de datos

text

Brachytherapy Begin Date
Descripción

BrachytherapyBeginDate

Tipo de datos

date

Brachytherapy End Date
Descripción

BrachytherapyEndDate

Tipo de datos

date

Brachytherapy Total Dose, Right
Descripción

BrachytherapyTotalDose,Right

Tipo de datos

float

Brachytherapy Total Dose, Left
Descripción

BrachytherapyTotalDose,Left

Tipo de datos

float

Brachytherapy Total Implant Count
Descripción

BrachytherapyTotalImplantCount

Tipo de datos

float

RT Begin Date
Descripción

RTBeginDate

Tipo de datos

date

RT End Date
Descripción

RTEndDate

Tipo de datos

date

RT Site
Descripción

RTSite

Tipo de datos

text

RT Site, Location Name
Descripción

RTSite,LocationName

Tipo de datos

text

RT Site, Other
Descripción

RTSite,Other

Tipo de datos

text

RT Total Dose
Descripción

RTTotalDose

Tipo de datos

float

RT Total Fraction Count
Descripción

RTTotalFractionCount

Tipo de datos

float

RT Site, Boost
Descripción

RTSite,Boost

Tipo de datos

text

RT Site, Other Boost
Descripción

RTSite,OtherBoost

Tipo de datos

text

RT Total Dose, Boost
Descripción

RTTotalDose,Boost

Tipo de datos

float

RT Total Fraction Count Boost
Descripción

RTTotalFractionCountBoost

Tipo de datos

float

RT Interruptions Ind
Descripción

RTInterruptionsInd

Tipo de datos

text

RT Interruptions Reason
Descripción

RTInterruptionsReason

Tipo de datos

text

RT Interruptions Reason, Medical
Descripción

RTInterruptionsReason,Medical

Tipo de datos

text

RT Interruptions Reason, Other
Descripción

RTInterruptionsReason,Other

Tipo de datos

text

Gyn: Treatment Modifications (radiation Therapy)
Descripción

Gyn: Treatment Modifications (radiation Therapy)

Dose Modification (Change)
Descripción

DoseModification(Change)

Tipo de datos

text

Dose Modification Reason
Descripción

DoseModificationReason

Tipo de datos

text

Gyn: Systemic Therapy-treatment Cycle Information
Descripción

Gyn: Systemic Therapy-treatment Cycle Information

Course Begin Date
Descripción

Chemotherapy Cycle Start Date

Tipo de datos

date

Alias
UMLS CUI-1
C1302181
UMLS CUI-2
C3173309
Course Identification
Descripción

CourseIdentification

Tipo de datos

float

Agent Total Dose (per course)
Descripción

AgentTotalDose(percourse)

Tipo de datos

float

Agent Dose Units
Descripción

AgentDoseUnits

Tipo de datos

text

Agent Name
Descripción

AgentName

Tipo de datos

text

Gyn: Treatment Modifications (systemic Therapy)
Descripción

Gyn: Treatment Modifications (systemic Therapy)

Dose Modification (Change)
Descripción

DoseModification(Change)

Tipo de datos

text

Dose Modification Reason
Descripción

DoseModificationReason

Tipo de datos

text

Allows Documentation Of Any Additional Cooments
Descripción

Allows Documentation Of Any Additional Cooments

Comments
Descripción

Comments

Tipo de datos

text

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No Instruction available.

1 formularios
  1. StudyEvent: Gynecologic Cancer - Treatment by Cycle Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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,LastName
Item
Person Completing Form, Last Name
text
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
Item Group
Gyn: Surgical Treatment
Item
Protocol Surgery Ind
text
CL.2
Code List
Protocol Surgery Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProtocolSurgeryDate
Item
Protocol Surgery Date
date
Item
Protocol Surgery Type
text
CL.3
Code List
Protocol Surgery Type
CL Item
Bilateral Salpingo-oophorectomy (bilateral salpingo-oophorectomy)
CL Item
Omentectomy (omentectomy)
C0198614 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
CL Item
Para-aortic Node Sampling/dissection (para-aortic node sampling/dissection)
CL Item
Unilateral Salpingo-oophorectomy (unilateral salpingo-oophorectomy)
C28012 (NCI Thesaurus)
C0205092 (UMLS 2011AA)
C15323 (NCI Thesaurus-3)
C0036132 (UMLS 2011AA-4)
CL Item
Pelvic Node Sampling/dissection (pelvic node sampling/dissection)
CL Item
Radical Hysterectomy (radical hysterectomy)
CL Item
Total Hysterectomy (total hysterectomy)
C15701 (NCI Thesaurus)
C0677962 (UMLS 2011AA)
CL Item
Partial Hysterectomy (partial hysterectomy)
C40961 (NCI Thesaurus)
C1270947 (UMLS 2011AA)
ProtocolSurgeryOtherType
Item
Protocol Surgery Other Type
text
Item
Protocol Surgery Reason
text
CL.4
Code List
Protocol Surgery Reason
CL Item
Interval Debulking (Interval debulking)
CL Item
Second Look Procedure (Second look procedure)
CL Item
Palliative Therapy (Palliative therapy)
CL Item
Other, Specify (Other, specify)
ProtocolSurgeryOtherReason
Item
Protocol Surgery Other Reason
text
ResidualDisease
Item
Residual Disease
float
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Item
Protocol Surgery, Qualifying Results Ind
text
CL.5
Code List
Protocol Surgery, Qualifying Results Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Applicable (not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Gyn: Treatment Modifications (surgical Treatment)
Item
Dose Modification (Change)
text
CL.15
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)
DoseModificationReason
Item
Dose Modification Reason
text
Item Group
Gyn: Radiation Therapy-treatment Cycle Information
Item
RT Type
text
CL.7
Code List
RT Type
CL Item
Adjuvant Rt (adjuvant RT)
CL Item
Brachytherapy (brachytherapy)
CL054378 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
CL Item
Neoadjuvant Rt (neoadjuvant RT)
CL Item
External Beam Radiation (external beam radiation)
RTOtherType
Item
RT Other Type
text
Item
Brachytherapy Application Method
text
CL.8
Code List
Brachytherapy Application Method
CL Item
Low Dose Rate (Low dose rate)
CL Item
High Dose Rate (High dose rate)
BrachytherapyBeginDate
Item
Brachytherapy Begin Date
date
BrachytherapyEndDate
Item
Brachytherapy End Date
date
BrachytherapyTotalDose,Right
Item
Brachytherapy Total Dose, Right
float
BrachytherapyTotalDose,Left
Item
Brachytherapy Total Dose, Left
float
BrachytherapyTotalImplantCount
Item
Brachytherapy Total Implant Count
float
RTBeginDate
Item
RT Begin Date
date
RTEndDate
Item
RT End Date
date
Item
RT Site
text
CL.9
Code List
RT Site
CL Item
Bladder (Bladder)
C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Specify First Location Or Primary Field (Location 1, specify)
CL Item
Specify Second Location Or Primary Field (Location 2, specify)
CL Item
Vagina (Vagina)
C12407 (NCI Thesaurus)
C0042232 (UMLS 2011AA)
CL Item
Specify Other Location Not Described (Other, specify)
CL Item
Pelvic Region (Pelvis)
CL Item
Rectum (Rectum)
C12390 (NCI Thesaurus)
C0034896 (UMLS 2011AA)
CL Item
Small Bowel (Small bowel)
CL Item
Specify Third Location Or Primary Field (Location 3, specify)
RTSite,LocationName
Item
RT Site, Location Name
text
RTSite,Other
Item
RT Site, Other
text
RTTotalDose
Item
RT Total Dose
float
RTTotalFractionCount
Item
RT Total Fraction Count
float
Item
RT Site, Boost
text
CL.10
Code List
RT Site, Boost
CL Item
None (none)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (other, specify)
CL Item
Vagina (vagina)
C12407 (NCI Thesaurus)
C0042232 (UMLS 2011AA)
CL Item
Pelvic Nodes (pelvic nodes)
CL Item
Para-aortic Nodes (para-aortic nodes)
RTSite,OtherBoost
Item
RT Site, Other Boost
text
RTTotalDose,Boost
Item
RT Total Dose, Boost
float
RTTotalFractionCountBoost
Item
RT Total Fraction Count Boost
float
Item
RT Interruptions Ind
text
CL.11
Code List
RT Interruptions Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (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
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
RT Interruptions Reason
text
CL.12
Code List
RT Interruptions Reason
CL Item
Medical Condition, Specify (medical condition, specify)
CL Item
Non-medical Reason (non-medical reason)
CL Item
Toxicity (toxicity)
C27990 (NCI Thesaurus)
C0600688 (UMLS 2011AA)
CL Item
Scheduling Problem (scheduling problem)
CL Item
Technical Problem (technical problem)
C49633 (NCI Thesaurus)
C1710348 (UMLS 2011AA)
CL Item
Other, Specify (other, specify)
RTInterruptionsReason,Medical
Item
RT Interruptions Reason, Medical
text
RTInterruptionsReason,Other
Item
RT Interruptions Reason, Other
text
Item Group
Gyn: Treatment Modifications (radiation Therapy)
Item
Dose Modification (Change)
text
CL.15
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)
DoseModificationReason
Item
Dose Modification Reason
text
Item Group
Gyn: Systemic Therapy-treatment Cycle Information
Chemotherapy Cycle Start Date
Item
Course Begin Date
date
C1302181 (UMLS CUI-1)
C3173309 (UMLS CUI-2)
CourseIdentification
Item
Course Identification
float
AgentTotalDose(percourse)
Item
Agent Total Dose (per course)
float
Item
Agent Dose Units
text
CL.14
Code List
Agent Dose Units
CL Item
Grays (Gy)
CL Item
Gram-equivalent Weight (Eq)
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
Centigrays (cGy)
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
Unit (unit)
C44278 (NCI Thesaurus)
C0439148 (UMLS 2011AA)
CL Item
Curie (Ci)
C0700085 (NCI Metathesaurus)
CL Item
Hertz (Hz)
AgentName
Item
Agent Name
text
Item Group
Gyn: Treatment Modifications (systemic Therapy)
Item
Dose Modification (Change)
text
CL.15
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)
DoseModificationReason
Item
Dose Modification Reason
text
Item Group
Allows Documentation Of Any Additional Cooments
Comments
Item
Comments
text
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