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ID
6933
Description
NCI Cooperative Group Treatment Summary Form (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C02140-B193-2659-E034-0003BA12F5E7
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Versions (2)
- 8/26/12 8/26/12 -
- 1/8/15 1/8/15 - Martin Dugas
Uploaded on
January 8, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT00014534 Treatment - NCI Cooperative Group Treatment Summary Form (CALGB-90104) - 2055978v3.0
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- StudyEvent: NCI Cooperative Group Treatment Summary Form (CALGB-90104)
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- StudyEvent: NCI Cooperative Group Treatment Summary Form (CALGB-90104)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
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)
C0805701 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate
text
PatientName,Last
Item
Patient Last Name (initials acceptable)
text
PatientName,First
Item
Patient First Name (initials acceptable)
text
PatientName,Middle
Item
Patient Middle Name (initials acceptable)
text
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)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
TreatmentFirstDoseBeginDate
Item
Date of First Dose for This Reporting Period
date
TreatmentLastDoseEndDate
Item
Date of Last Dose for This Reporting Period
date
TotalCourseNumber
Item
Total Number of cycles Given
float
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
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
Disease Progression, Relapse During Active Treatment (Disease recurrence)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Other (Other complicating disease)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
OffTreatmentReason,Other
Item
Other, specify
text
Item
Were there any dose modificiations or additions/omissions to protocol treatment? (check one)
text
Code List
Were there any dose modificiations or additions/omissions to protocol treatment? (check one)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
DoseModificationReason
Item
Specify (if yes, unplanned)
text