ID
7423
Description
CALGB 80702 Treatment Form Oxaliplatin, Leucovorin Calcium, and Fluorouracil With or Without Celecoxib in Treating Patients With Stage III Colon Cancer Previously Treated With Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7AD9B90F-EC60-48A2-E040-BB89AD430CF4
Link
Keywords
Versions (2)
- 8/27/12 8/27/12 -
- 1/9/15 1/9/15 - Martin Dugas
Uploaded on
January 9, 2015
DOI
To request one please log in.
License
Creative Commons BY-NC 3.0 Legacy
Model comments :
You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.
Itemgroup comments for :
Item comments for :
In order to download data models you must be logged in. Please log in or register for free.
Colorectal Cancer NCT01150045 Treatment - CALGB 80702 Treatment Form - 2969857v1.0
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the form
Description
Unnamed2
Description
Patient Initials
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Description
Medical Record Number
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C1301894
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25261
- NCI Thesaurus Property-2
- C25198
Description
Institution Name
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS CUI-1
- C1301943
- NCI Thesaurus ObjectClass-2
- C21541
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25191
- NCI Thesaurus ValueDomain-2
- C21541
Description
Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2347449
- NCI Thesaurus ObjectClass
- C25608
- NCI Thesaurus ObjectClass-2
- C17005
- NCI Thesaurus Property
- C25364
Description
Study Number Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Trial subject ID Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Patient Data
Description
Cycle Number
Data type
integer
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2045829
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25379
Description
Cycle Number
Data type
integer
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2045829
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25379
Description
Body Surface Area
Data type
float
Measurement units
- m2
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS CUI-1
- C0005902
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus Property
- C25157
Description
First Treatment (cycles 1 ¿ 6)
Description
Agent
Data type
text
Alias
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1521826
- NCI Thesaurus ObjectClass
- C1708
- NCI Thesaurus ValueDomain
- C1708
- NCI Thesaurus ValueDomain-2
- C42614
Description
Agent Total Dose
Data type
float
Alias
- NCI Thesaurus ValueDomain
- C25304
- UMLS CUI-1
- C2986497
- NCI Thesaurus Property
- C25379
- NCI Thesaurus ValueDomain-2
- C25488
- NCI Thesaurus ObjectClass
- C1708
Description
Dose Modifications
Description
Dose Modification
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1707811
- NCI Thesaurus ObjectClass
- C25256
- NCI Thesaurus Property
- C25572
- NCI Thesaurus ValueDomain-2
- C25572
Description
Reason Treatment Ended
Description
PlaceboCelecoxibAgentNotAdministeredTotalDoseCount
Data type
float
Alias
- NCI Thesaurus ObjectClass
- C753
- UMLS 2011AA ObjectClass
- C0032042
- NCI Thesaurus ObjectClass-2
- C1708
- UMLS 2011AA ObjectClass-2
- C0450442
- NCI Thesaurus ObjectClass-3
- C1728
- UMLS 2011AA ObjectClass-3
- C0538926
- NCI Thesaurus Property
- C25594
- UMLS 2011AA Property
- C1518422
- NCI Thesaurus Property-2
- C25382
- UMLS 2011AA Property-2
- C1521801
- NCI Thesaurus ValueDomain
- C25463
- UMLS 2011AA ValueDomain
- C0750480
Description
Off Treatment Reason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS CUI-1
- C1518544
- NCI Thesaurus ObjectClass
- C25601
- UMLS CUI-2
- C0566251
- NCI Thesaurus Property
- C25365
Description
Off Treatment Reason, specify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS CUI-1
- C1518544
- NCI Thesaurus ObjectClass
- C25601
- UMLS CUI-2
- C0566251
- NCI Thesaurus Property
- C25365
- UMLS CUI-3
- C1521902
Description
Supportive Care non-Protocol
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS CUI-1
- C0344211
- NCI Thesaurus Property
- C15368
- NCI Thesaurus ObjectClass
- C25590
- UMLS CUI-2
- C1518384
- NCI Thesaurus ObjectClass-2
- C37902
Description
Supportive Care non-Protocol, specify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C0344211
- NCI Thesaurus Property
- C15368
- NCI Thesaurus ObjectClass
- C25590
- UMLS CUI-2
- C1518384
- NCI Thesaurus ObjectClass-2
- C37902
- UMLS CUI-3
- C1521902
Description
Overall Response
Description
Person Completing Form
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C1550483
- NCI Thesaurus ObjectClass
- C25657
- NCI Thesaurus Property
- C25364
Description
Form Completion Date
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C19464
- UMLS CUI-1
- C1549507
- NCI Thesaurus Property
- C25250
- NCI Thesaurus Property-2
- C25604
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25367
Similar models
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the form
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
C25509 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25256 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2045829 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C2045829 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C0005902 (UMLS CUI-1)
C25712 (NCI Thesaurus ValueDomain)
C25157 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C2986497 (UMLS CUI-1)
C25379 (NCI Thesaurus Property)
C25488 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C1707811 (UMLS CUI-1)
C25256 (NCI Thesaurus ObjectClass)
C25572 (NCI Thesaurus Property)
C25572 (NCI Thesaurus ValueDomain-2)
C1298908 (UMLS 2011AA)
C0032042 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C1728 (NCI Thesaurus ObjectClass-3)
C0538926 (UMLS 2011AA ObjectClass-3)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C1518544 (UMLS CUI-1)
C25601 (NCI Thesaurus ObjectClass)
C0566251 (UMLS CUI-2)
C25365 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA)
C1518544 (UMLS CUI-1)
C25601 (NCI Thesaurus ObjectClass)
C0566251 (UMLS CUI-2)
C25365 (NCI Thesaurus Property)
C1521902 (UMLS CUI-3)
C0344211 (UMLS CUI-1)
C15368 (NCI Thesaurus Property)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS CUI-2)
C37902 (NCI Thesaurus ObjectClass-2)
C0344211 (UMLS CUI-1)
C15368 (NCI Thesaurus Property)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS CUI-2)
C37902 (NCI Thesaurus ObjectClass-2)
C1521902 (UMLS CUI-3)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)