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ID

7119

Beschrijving

NCCTG Study N0147 Colonoscopy Report Submission Form Comparison of Combination Chemotherapy Regimens With or Without Cetuximab in Treating Patients Who Have Undergone Surgery For Stage III Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=224EC566-3DBB-4732-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=224EC566-3DBB-4732-E044-0003BA3F9857

Trefwoorden

  1. 27-08-12 27-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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    Colorectal Cancer NCT00079274 Treatment - NCCTG Study N0147 Colonoscopy Report Submission Form - 2542336v1.0

    Instructions: Attach each report to a separart Submission Form. Always submit with an NCCTG Data Submission Cover Sheet.

    Header
    Beschrijving

    Header

    Coordinating Group Protocol Number
    Beschrijving

    Protocol ID Coordinating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1711341
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Coordinating Group Code
    Beschrijving

    Coordinating Group Code

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS CUI-1
    C1711341
    NCI Thesaurus ObjectClass
    C17005
    UMLS CUI-2
    C0805701
    NCI Thesaurus ObjectClass-2
    C25462
    NCI Thesaurus Property
    C25364
    Protocol Title
    Beschrijving

    Protocol Title

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986303
    NCI Thesaurus ObjectClass
    C25320
    NCI Thesaurus Property
    C42774
    Patient Study ID
    Beschrijving

    Patient Study ID

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Patient Medical Record Number
    Beschrijving

    Medical Record Number

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301894
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25261
    NCI Thesaurus Property-2
    C25198
    Patient Initials (L, FM)
    Beschrijving

    Patient Initials

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Participating Group Code (Cooperative Group where credit will be applied)
    Beschrijving

    ParticipatingGroupIdentifierCode

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C25608
    UMLS 2011AA ObjectClass
    C0679823
    NCI Thesaurus ObjectClass-2
    C17005
    UMLS 2011AA ObjectClass-2
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution Name (Treating institution/performance site)
    Beschrijving

    Institution Name

    Datatype

    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 data are amended, please circle in red when using paper form)
    Beschrijving

    Data amended

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Reporting Period
    Beschrijving

    Clinical Trial Period

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2347804
    NCI Thesaurus ObjectClass
    C25214
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass-2
    C25651
    Procedure Date (mm dd yyyy)
    Beschrijving

    Surgery Date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1628561
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C15329
    NCI Thesaurus Property
    C25275
    Submission Form Completed by (print name)
    Beschrijving

    CaseReportFormTransmissionDocumentSubmittedName

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C19498
    UMLS 2011AA Property
    C1547673
    NCI Thesaurus Property-2
    C25695
    UMLS 2011AA Property-2
    C1515023
    NCI Thesaurus Property-3
    C17214
    UMLS 2011AA Property-3
    C0242781
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383

    Similar models

    Instructions: Attach each report to a separart Submission Form. Always submit with an NCCTG Data Submission Cover Sheet.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Header
    Protocol ID Coordinating Group
    Item
    Coordinating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1711341 (UMLS CUI-2)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Coordinating Group Code
    Item
    Coordinating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C1711341 (UMLS CUI-1)
    C17005 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25462 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Protocol Title
    Item
    Protocol Title
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986303 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C42774 (NCI Thesaurus Property)
    Patient Study ID
    Item
    Patient Study ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Medical Record Number
    Item
    Patient Medical Record Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301894 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    Patient Initials
    Item
    Patient Initials (L, FM)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    ParticipatingGroupIdentifierCode
    Item
    Participating Group Code (Cooperative Group where credit will be applied)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C1257890 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Institution Name
    Item
    Institution Name (Treating institution/performance site)
    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 data are amended, please circle in red when using paper form)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item
    Reporting Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2347804 (UMLS CUI-1)
    C25214 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C25651 (NCI Thesaurus ObjectClass-2)
    Code List
    Reporting Period
    CL Item
    Pre-therapy (Pre-treatment)
    C54734 (NCI Thesaurus)
    C1882440 (UMLS 2011AA)
    CL Item
    Post-treatment (Post-Treatment)
    CL024863 (NCI Metathesaurus)
    Surgery Date
    Item
    Procedure Date (mm dd yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1628561 (UMLS CUI-1)
    C25367 (NCI Thesaurus ValueDomain-2)
    C15329 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    CaseReportFormTransmissionDocumentSubmittedName
    Item
    Submission Form Completed by (print name)
    text
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C19498 (NCI Thesaurus Property)
    C1547673 (UMLS 2011AA Property)
    C25695 (NCI Thesaurus Property-2)
    C1515023 (UMLS 2011AA Property-2)
    C17214 (NCI Thesaurus Property-3)
    C0242781 (UMLS 2011AA Property-3)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)

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