0 Beoordelingen

ID

7518

Beschrijving

SOUTHWEST ONCOLOGY GROUP S0347 TREATMENT FORM Vinorelbine With or Without Trastuzumab in Treating Women With Progressive Metastatic Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DDB236B7-9161-179E-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DDB236B7-9161-179E-E034-0003BA12F5E7

Trefwoorden

  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Itemgroep Commentaren voor :

Item Commentaren voor :


    Geen commentaren

    U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

    Breast Cancer NCT00103233 Treatment - SOUTHWEST ONCOLOGY GROUP S0347 TREATMENT FORM - 2285534v3.0

    No Instruction available.

    1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0347 TREATMENT FORM
      1. No Instruction available.
    Header
    Beschrijving

    Header

    SWOG Patient ID
    Beschrijving

    Trial subject ID SWOG

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    SWOG Study No.
    Beschrijving

    Protocol ID SWOG

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Registration Step
    Beschrijving

    Registration Number

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Cycle Number (see instructions)
    Beschrijving

    Cycle Number Chemotherapeutics

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property-2
    C25379
    Patient Initials (L, F M)
    Beschrijving

    Patient Initials

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution/Affiliate
    Beschrijving

    Institution Name

    Datatype

    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
    Physician
    Beschrijving

    Investigator Name

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Participating Group Name
    Beschrijving

    Participating Group

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Participating Study No.
    Beschrijving

    Study Number Participating Group

    Datatype

    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
    Participating Patient ID (Instructions: Please complete this form after each cycle 1 cycle = 4 weeks. All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form.)
    Beschrijving

    Trial subject ID Participating Group

    Datatype

    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
    Status
    Beschrijving

    Status

    Date of Last Contact or Death
    Beschrijving

    PatientLastContactDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25461
    UMLS 2011AA Property
    C0337611
    Vital Status
    Beschrijving

    PatientVitalStatus

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C18003
    UMLS 2011AA ValueDomain
    C0442732
    NCI Thesaurus ValueDomain-2
    C25688
    UMLS 2011AA ValueDomain-2
    C0449438
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Has the patient progressed per the definition in Section 10.0 of the protocol?
    Beschrijving

    Tumor Progression

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0178874
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25320
    NCI Thesaurus Property-2
    C19987
    Treatment For This Cycle
    Beschrijving

    Treatment For This Cycle

    Assigned Treatment Arm
    Beschrijving

    Protocol Treatment Arm

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C42651
    UMLS CUI-1
    C1522541
    NCI Thesaurus Property
    C32141
    NCI Thesaurus Property-2
    C25426
    NCI Thesaurus ValueDomain
    C25284
    Cycle start date
    Beschrijving

    Chemotherapy Cycle Start Date

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1302181
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS CUI-2
    C3173309
    NCI Thesaurus Property
    C25379
    Weight first day this cycle
    Beschrijving

    Patient Weight

    Datatype

    float

    Maateenheden
    • Kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS CUI-1
    C0005910
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25208
    Kg
    Date of last treatment for this cycle
    Beschrijving

    TreatmentCycleEndDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25472
    UMLS 2011AA Property
    C1511572
    NCI Thesaurus ObjectClass
    C15368
    BSA first day this cycle
    Beschrijving

    Body Surface Area

    Datatype

    float

    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS CUI-1
    C0005902
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25157
    Were there any dose modifications or additions/omissions to protocol treatment?
    Beschrijving

    Dose Modification

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS CUI-1
    C1707811
    NCI Thesaurus ObjectClass
    C25256
    NCI Thesaurus Property
    C25572
    NCI Thesaurus ValueDomain-2
    C25572
    Unnamed question 2
    Beschrijving

    AdministeredAgentDayCourseType

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C41161
    UMLS 2011AA ObjectClass
    C1521826
    NCI Thesaurus ObjectClass-2
    C25382
    UMLS 2011AA ObjectClass-2
    C1521801
    NCI Thesaurus Property
    C25301
    UMLS 2011AA Property
    C0439228
    NCI Thesaurus Property-2
    C25379
    UMLS 2011AA Property-2
    C0750729
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Unnamed question 3
    Beschrijving

    Agent

    Datatype

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS CUI-1
    C1521826
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain
    C1708
    NCI Thesaurus ValueDomain-2
    C42614
    Dose
    Beschrijving

    Medication Dose

    Datatype

    float

    Alias
    NCI Thesaurus ValueDomain
    C25488
    UMLS CUI-1
    C3174092
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus ValueDomain-2
    C1708
    NCI Thesaurus Property
    C25382
    Comments
    Beschrijving

    Comments

    Comments
    Beschrijving

    Research Comments

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393

    Similar models

    No Instruction available.

    1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0347 TREATMENT FORM
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Header
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Protocol ID SWOG
    Item
    SWOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Cycle Number Chemotherapeutics
    Item
    Cycle Number (see instructions)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    C25379 (NCI Thesaurus 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 Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Investigator Name
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Participating Group
    Item
    Participating Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Patient ID (Instructions: Please complete this form after each cycle 1 cycle = 4 weeks. All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    Status
    PatientLastContactDate
    Item
    Date of Last Contact or Death
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25461 (NCI Thesaurus Property)
    C0337611 (UMLS 2011AA Property)
    Item
    Vital Status
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C18003 (NCI Thesaurus ValueDomain)
    C0442732 (UMLS 2011AA ValueDomain)
    C25688 (NCI Thesaurus ValueDomain-2)
    C0449438 (UMLS 2011AA ValueDomain-2)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    Code List
    Vital Status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    Tumor Progression
    Item
    Has the patient progressed per the definition in Section 10.0 of the protocol?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C0178874 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25320 (NCI Thesaurus Property)
    C19987 (NCI Thesaurus Property-2)
    Item Group
    Treatment For This Cycle
    Item
    Assigned Treatment Arm
    text
    C15368 (NCI Thesaurus ObjectClass)
    C42651 (NCI Thesaurus ObjectClass-2)
    C1522541 (UMLS CUI-1)
    C32141 (NCI Thesaurus Property)
    C25426 (NCI Thesaurus Property-2)
    C25284 (NCI Thesaurus ValueDomain)
    Code List
    Assigned Treatment Arm
    CL Item
    Arm 1 (Arm 1)
    CL Item
    Arm 2 (Arm 2)
    Chemotherapy Cycle Start Date
    Item
    Cycle start date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1302181 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25431 (NCI Thesaurus ValueDomain-2)
    C3173309 (UMLS CUI-2)
    C25379 (NCI Thesaurus Property)
    Patient Weight
    Item
    Weight first day this cycle
    float
    C25209 (NCI Thesaurus ValueDomain)
    C0005910 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25208 (NCI Thesaurus Property)
    TreatmentCycleEndDate
    Item
    Date of last treatment for this cycle
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25472 (NCI Thesaurus Property)
    C1511572 (UMLS 2011AA Property)
    C15368 (NCI Thesaurus ObjectClass)
    Body Surface Area
    Item
    BSA first day this cycle
    float
    C25209 (NCI Thesaurus ValueDomain)
    C0005902 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25157 (NCI Thesaurus Property)
    Item
    Were there any dose modifications or additions/omissions to protocol treatment?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1707811 (UMLS CUI-1)
    C25256 (NCI Thesaurus ObjectClass)
    C25572 (NCI Thesaurus Property)
    C25572 (NCI Thesaurus ValueDomain-2)
    Code List
    Were there any dose modifications or additions/omissions to protocol treatment?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
    CL Item
    Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
    Item
    Unnamed question 2
    text
    C41161 (NCI Thesaurus ObjectClass)
    C1521826 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus ObjectClass-2)
    C1521801 (UMLS 2011AA ObjectClass-2)
    C25301 (NCI Thesaurus Property)
    C0439228 (UMLS 2011AA Property)
    C25379 (NCI Thesaurus Property-2)
    C0750729 (UMLS 2011AA Property-2)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Unnamed question 2
    CL Item
    Day 1 (Day 1)
    CL Item
    Day 8 (Day 8)
    CL Item
    Day 15 (Day 15)
    CL Item
    Day 22 (Day 22)
    Item
    Unnamed question 3
    text
    C25364 (NCI Thesaurus Property)
    C1521826 (UMLS CUI-1)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C42614 (NCI Thesaurus ValueDomain-2)
    Code List
    Unnamed question 3
    CL Item
    Vinorelbine (Vinorelbine)
    CL Item
    Trastuzumab (Trastuzumab)
    Medication Dose
    Item
    Dose
    float
    C25488 (NCI Thesaurus ValueDomain)
    C3174092 (UMLS CUI-1)
    C1708 (NCI Thesaurus ObjectClass)
    C1708 (NCI Thesaurus ValueDomain-2)
    C25382 (NCI Thesaurus Property)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial