ID

6934

Description

NCI Cooperative Group Toxicity 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=A9BEFBAB-CF40-25AD-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9BEFBAB-CF40-25AD-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 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 Toxicity - NCI Cooperative Group Toxicity Form (CALGB-90104) - 2056157v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: NCI Cooperative Group Toxicity Form (CALGB-90104)
    1. No Instruction available.
Mskcc 00-138; Calgb 90104; Ecog
Description

Mskcc 00-138; Calgb 90104; Ecog

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
Description

AffiliateName

Data type

text

Patient Last Name (initials acceptable)
Description

PatientName,Last

Data type

text

Patient First Name (initials acceptable)
Description

PatientName,First

Data type

text

Patient Middle Name (initials acceptable)
Description

PatientName,Middle

Data type

text

Form Administration
Description

Form Administration

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

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
Are data amended? (If data are amended, please circle in red when using paper form)
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Adverse Events
Description

Adverse Events

CTC Adverse Event Term
Description

CTCAdverseEventTerm

Data type

text

Adverse Event Reporting From Date
Description

CTCAdverseEventReportBeginDate

Data type

date

Adverse Event Reporting To Date
Description

CTCAdverseEventReportEndDate

Data type

date

CTC Adverse Event Grade
Description

CTCAdverseEventGrade

Data type

text

CTC Adverse Event Attribution Code
Description

CTCAdverseEventAttributionCode

Data type

text

Treatment?
Description

ProtocolTreatmentInd

Data type

boolean

SAE filed?
Description

SAEfiled?

Data type

boolean

Ccrr Module For Nci Cooperative Group Toxicity Form (calgb-90104)
Description

Ccrr Module For Nci Cooperative Group Toxicity Form (calgb-90104)

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: NCI Cooperative Group Toxicity Form (CALGB-90104)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Mskcc 00-138; Calgb 90104; Ecog
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
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
Item Group
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)
AmendedDataInd
Item
Are data amended? (If data are amended, please circle in red when using paper form)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Adverse Events
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
CTCAdverseEventReportBeginDate
Item
Adverse Event Reporting From Date
date
CTCAdverseEventReportEndDate
Item
Adverse Event Reporting To Date
date
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
Item
CTC Adverse Event Attribution Code
text
CL.2
Code List
CTC Adverse Event Attribution Code
CL Item
Unrelated (unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely)
CL Item
Possibly (possibly)
CL Item
Probably (probably)
CL Item
Definitely (definitely)
ProtocolTreatmentInd
Item
Treatment?
boolean
SAEfiled?
Item
SAE filed?
boolean
Item Group
Ccrr Module For Nci Cooperative Group Toxicity Form (calgb-90104)
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