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7015

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North Central Cancer Treatment Group N0577 Concurrent Treatment Form - Active Monitoring Phase Radiation Therapy or Radiation Therapy and Temozolomide or Temozolomide Alone in Treating Patients With Newly Diagnosed Anaplastic Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C0902A6-F47D-2EB7-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C0902A6-F47D-2EB7-E044-0003BA3F9857

Nyckelord

Versioner (2)
  1. 2012-08-26 2012-08-26 -
  2. 2015-01-08 2015-01-08 - Martin Dugas
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8 januari 2015

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Creative Commons BY-NC 3.0 Legacy
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    Brain and Central Nervous System Tumors NCT00887146 Treatment - North Central Cancer Treatment Group N0577 Concurrent Treatment Form - Active Monitoring Phase - 2745292v1.0

    Engelsk

    ALL ITEMS MUST BE COMPLETED

    1 Formulär  
    1. StudyEvent: North Central Cancer Treatment Group N0577 Concurrent Treatment Form - Active Monitoring Phase
      1. ALL ITEMS MUST BE COMPLETED
    Header
    Beskrivning

    Header

    Protocol Number
    Beskrivning

    Protocol ID NCCTG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1518419
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25581
    Patient ID
    Beskrivning

    PatientNorthCentralCancerTreatmentGroupIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25581
    UMLS 2011AA Property-2
    C1518419
    Patient Initials (L F M)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution Number
    Beskrivning

    Institution Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Institution
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Are data amended (If yes, highlight amended areas)
    Beskrivning

    Data amended

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Header
    Beskrivning

    Header

    Current Cycle Number
    Beskrivning

    Cycle Number Chemotherapeutics

    Datatyp

    integer

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property-2
    C25379
    Date of evaluation (mm/dd/yyyy)
    Beskrivning

    Assessment Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2985720
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C38000
    Has there been any change in medications since the previous visit
    Beskrivning

    PatientReportChangeInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25375
    UMLS 2011AA Property
    C0684224
    NCI Thesaurus Property-2
    C25446
    UMLS 2011AA Property-2
    C0392747
    Concomitant Medication (If Yes, enter medications including prescription, over-the-counter, and alternative medications that have not been previously reported or no longer being taken)
    Beskrivning

    Concomitant Medication

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2347852
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus Property
    C25639
    NCI Thesaurus ObjectClass-2
    C25730
    Concomitant Medication Reason
    Beskrivning

    ConcomitantMedicationAdministeredReason

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C459
    UMLS 2011AA ObjectClass
    C0013227
    NCI Thesaurus ObjectClass-2
    C25730
    UMLS 2011AA ObjectClass-2
    C0521115
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Dose
    Beskrivning

    ConcomitantMedicationAdministeredDose

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C459
    UMLS 2011AA ObjectClass
    C0013227
    NCI Thesaurus ValueDomain
    C25488
    UMLS 2011AA ValueDomain
    C0178602
    NCI Thesaurus ObjectClass-2
    C25730
    UMLS 2011AA ObjectClass-2
    C0521115
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Schedule
    Beskrivning

    MedicationScheduleDescriptiveText

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25211
    UMLS 2011AA Property
    C0086960
    NCI Thesaurus ObjectClass
    C25409
    UMLS 2011AA ObjectClass
    C1533734
    Tillbaka till toppen

    Similar models

    ALL ITEMS MUST BE COMPLETED

    1 Formulär
    1. StudyEvent: North Central Cancer Treatment Group N0577 Concurrent Treatment Form - Active Monitoring Phase
      1. ALL ITEMS MUST BE COMPLETED
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header
    Protocol ID NCCTG
    Item
    Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1518419 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25581 (NCI Thesaurus Property-2)
    PatientNorthCentralCancerTreatmentGroupIdentifierNumber
    Item
    Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25581 (NCI Thesaurus Property-2)
    C1518419 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials (L F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Institution Name
    Item
    Institution
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Data amended
    Item
    Are data amended (If yes, highlight amended areas)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Header
    Cycle Number Chemotherapeutics
    Item
    Current Cycle Number
    integer
    C25337 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    C25379 (NCI Thesaurus Property-2)
    Assessment Date
    Item
    Date of evaluation (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2985720 (UMLS CUI-1)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C38000 (NCI Thesaurus Property)
    PatientReportChangeInd-2
    Item
    Has there been any change in medications since the previous visit
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25375 (NCI Thesaurus Property)
    C0684224 (UMLS 2011AA Property)
    C25446 (NCI Thesaurus Property-2)
    C0392747 (UMLS 2011AA Property-2)
    Concomitant Medication
    Item
    Concomitant Medication (If Yes, enter medications including prescription, over-the-counter, and alternative medications that have not been previously reported or no longer being taken)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2347852 (UMLS CUI-1)
    C459 (NCI Thesaurus ObjectClass)
    C25639 (NCI Thesaurus Property)
    C25730 (NCI Thesaurus ObjectClass-2)
    Item
    Concomitant Medication Reason
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C459 (NCI Thesaurus ObjectClass)
    C0013227 (UMLS 2011AA ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C0521115 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    CL.3
    Code List
    Concomitant Medication Reason
    CL Item
    Dose And/or Schedule Change (Dose and/or schedule change)
    CL Item
    Medication No Longer Being Taken (Medication no longer being taken)
    CL Item
    New Medication (New medication)
    ConcomitantMedicationAdministeredDose
    Item
    Dose
    float
    C459 (NCI Thesaurus ObjectClass)
    C0013227 (UMLS 2011AA ObjectClass)
    C25488 (NCI Thesaurus ValueDomain)
    C0178602 (UMLS 2011AA ValueDomain)
    C25730 (NCI Thesaurus ObjectClass-2)
    C0521115 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    MedicationScheduleDescriptiveText
    Item
    Schedule
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25211 (NCI Thesaurus Property)
    C0086960 (UMLS 2011AA Property)
    C25409 (NCI Thesaurus ObjectClass)
    C1533734 (UMLS 2011AA ObjectClass)
    Tillbaka till toppen 

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