ID

7556

Descrizione

GOG-0240 Common Toxicity Reporting Form (Form T) Paclitaxel and Cisplatin or Topotecan With or Without Bevacizumab in Treating Patients With Stage IVB, Recurrent, or Persistent Cervical Cancer NCT00803062 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=45815094-13E7-14B9-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=45815094-13E7-14B9-E044-0003BA3F9857

Keywords

  1. 27/08/12 27/08/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
  3. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy

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Toxicity Reporting Form Cervical Cancer (NCT00803062)

No Instruction available.

  1. StudyEvent: GOG-0240 Common Toxicity Reporting Form (Form T)
    1. No Instruction available.
Header Module
Descrizione

Header Module

Date form originally completed (m d y)
Descrizione

Form Completion Date

Tipo di dati

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
Date form amended (m d y)
Descrizione

Amendment date

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25416
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI-1
C0680532
UMLS CUI-2
C0011008
Person amending form, last name
Descrizione

Person Amending Form

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25364
UMLS CUI-1
C0680532
UMLS CUI-2
C1547383
Patient Initials (First, Middle, Last)
Descrizione

Patient Initials

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Study ID
Descrizione

Patient ID GOG

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25521
UMLS CUI-1
C2348585
UMLS CUI-2
C1512288
COMMENTS
Descrizione

Research Comments

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Person Completing Form, Last Name
Descrizione

Person Completing Form Last Name

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass-2
C25657
UMLS CUI-2
C1301584
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25551
NCI Thesaurus ValueDomain
C25191
Adverse Events - Section 1
Descrizione

Adverse Events - Section 1

Current Cycle Number
Descrizione

Cycle Number Chemotherapeutics

Tipo di dati

integer

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2045829
NCI Thesaurus Property
C25471
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25379
Has the patient received any transfusions during this course of therapy?
Descrizione

Transfusion

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus ObjectClass
C15366
NCI Thesaurus Property
C25382
UMLS CUI-1
C1879316
Was patient hospitalized as a result of reported adverse events?
Descrizione

Hospitalization

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus ObjectClass-2
C25182
NCI Thesaurus Property
C25385
UMLS CUI-1
C0019993
Were cytokines administered this course?
Descrizione

Cytokine Therapy

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C20464
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property-2
C25382
UMLS CUI-1
C0199974
Yes specify
Descrizione

Cytokine Therapy, specify

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C20464
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property-2
C25382
UMLS CUI-1
C0199974
Adverse Events - Section 2
Descrizione

Adverse Events - Section 2

Peripheral WBC count done
Descrizione

WBC done

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0023508
Peripheral WBC count (1000/mm3)
Descrizione

Leukocytes (WBC)

Tipo di dati

float

Unità di misura
  • 1000/uL
Alias
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0023508
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C38024
1000/uL
WBC Date
Descrizione

WBC date

Tipo di dati

date

Unità di misura
  • m d y
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0023508
UMLS CUI-2
C0011008
m d y
CTC Adverse Event Grade
Descrizione

CTC Adverse Event Grade

Tipo di dati

integer

Alias
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus ValueDomain
C18000
NCI Thesaurus Property
C25365
UMLS CUI-1
C2985911
CTC Adverse Event Attribution Scale
Descrizione

CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)

Tipo di dati

integer

Alias
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25358
UMLS CUI-1
C1706735
SAE report submitted
Descrizione

SAE report

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C41331
NCI Thesaurus Property
C25375
NCI Thesaurus ObjectClass-2
C54035
UMLS CUI-1
C1519255
UMLS CUI-2
C0684224
Peripheral ANC/Granulocytes count done
Descrizione

ANC

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12530
NCI Thesaurus Property-3
C63321
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0948762
Peripheral Granulocytes count (ANC/ 1000/mm3)
Descrizione

Granulocyte count

Tipo di dati

float

Unità di misura
  • 1000/uL
Alias
NCI Thesaurus Property
C20200
UMLS CUI-1
C0857490
NCI Thesaurus Property-2
C12530
NCI Thesaurus ValueDomain
C25463
NCI Thesaurus ObjectClass
C25294
1000/uL
Date
Descrizione

Neutrophils date

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C12533
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0200633
UMLS CUI-2
C0011008
Peripheral Platelet count done
Descrizione

Platelets

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0005821
Peripheral Platelet count (mm3)
Descrizione

Platelets

Tipo di dati

float

Unità di misura
  • 1000/uL
Alias
NCI Thesaurus Property
C20200
UMLS CUI-1
C0005821
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
1000/uL
Date
Descrizione

Platelets date

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0005821
NCI Thesaurus Property
C20200
UMLS CUI-2
C0011008
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
Hemoglobin done
Descrizione

Hemoglobin

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0019046
Hemoglobin
Descrizione

Hemoglobin

Tipo di dati

float

Unità di misura
  • g/dL
Alias
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
UMLS CUI-1
C0019046
g/dL
Date
Descrizione

Hemoglobin Date

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0019046
UMLS CUI-2
C0011008
Adverse Events - Section 3
Descrizione

Adverse Events - Section 3

CTC Adverse Event Term
Descrizione

CTC Adverse Event Reported Term

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C45559
UMLS CUI-1
C1516728
UMLS CUI-2
C2826934
Other, specify
Descrizione

CTC Adverse Event Reported Term

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25161
UMLS CUI-1
C1516728
UMLS CUI-2
C2699044
Adverse Event Onset Date
Descrizione

Adverse Event Onset Date

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25279
UMLS CUI-1
C2985916
AE Present Status
Descrizione

Adverse Event Outcome

Tipo di dati

text

Alias
NCI Thesaurus Property
C25626
NCI Thesaurus ObjectClass
C41331
NCI Thesaurus ValueDomain
C25688
UMLS CUI-1
C1705586
The CTCAE data entered above is
Descrizione

CTCAE version

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25714
UMLS CUI-1
C1516728
UMLS CUI-2
C0333052

Similar models

No Instruction available.

  1. StudyEvent: GOG-0240 Common Toxicity Reporting Form (Form T)
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header Module
Form Completion Date
Item
Date form originally completed (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Amendment date
Item
Date form amended (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0680532 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C1547383 (UMLS CUI-2)
Patient Initials
Item
Patient Initials (First, Middle, Last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID GOG
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25521 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C1512288 (UMLS CUI-2)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Item Group
Adverse Events - Section 1
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)
Item
Has the patient received any transfusions during this course of therapy?
text
C25180 (NCI Thesaurus ValueDomain)
C15366 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1879316 (UMLS CUI-1)
Code List
Has the patient received any transfusions during this course of therapy?
CL Item
No Transfusion (No)
CL Item
Transfusion With Red Blood Cells (Yes, red blood cells)
CL Item
Transfusion With Platelets (Yes, platelets)
Hospitalization
Item
Was patient hospitalized as a result of reported adverse events?
boolean
C38148 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25182 (NCI Thesaurus ObjectClass-2)
C25385 (NCI Thesaurus Property)
C0019993 (UMLS CUI-1)
Cytokine Therapy
Item
Were cytokines administered this course?
boolean
C38148 (NCI Thesaurus ValueDomain)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0199974 (UMLS CUI-1)
Cytokine Therapy, specify
Item
Yes specify
text
C25685 (NCI Thesaurus ValueDomain)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0199974 (UMLS CUI-1)
Item Group
Adverse Events - Section 2
WBC done
Item
Peripheral WBC count done
boolean
C38148 (NCI Thesaurus ValueDomain)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0023508 (UMLS CUI-1)
Leukocytes (WBC)
Item
Peripheral WBC count (1000/mm3)
float
C25294 (NCI Thesaurus ObjectClass)
C0023508 (UMLS CUI-1)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C38024 (NCI Thesaurus ValueDomain-2)
WBC date
Item
WBC Date
date
C25164 (NCI Thesaurus ValueDomain)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0023508 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
CTC Adverse Event Grade
Item
CTC Adverse Event Grade
integer
C49704 (NCI Thesaurus ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C25365 (NCI Thesaurus Property)
C2985911 (UMLS CUI-1)
Item
CTC Adverse Event Attribution Scale
integer
C25664 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25358 (NCI Thesaurus Property)
C1706735 (UMLS CUI-1)
Code List
CTC Adverse Event Attribution Scale
CL Item
Unrelated (1)
CL Item
Unlikely (2)
CL Item
Possible (3)
CL Item
Probable (4)
CL Item
Definite (5)
SAE report
Item
SAE report submitted
boolean
C38148 (NCI Thesaurus ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C25375 (NCI Thesaurus Property)
C54035 (NCI Thesaurus ObjectClass-2)
C1519255 (UMLS CUI-1)
C0684224 (UMLS CUI-2)
ANC
Item
Peripheral ANC/Granulocytes count done
boolean
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C12530 (NCI Thesaurus Property-2)
C63321 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C0948762 (UMLS CUI-1)
Granulocyte count
Item
Peripheral Granulocytes count (ANC/ 1000/mm3)
float
C20200 (NCI Thesaurus Property)
C0857490 (UMLS CUI-1)
C12530 (NCI Thesaurus Property-2)
C25463 (NCI Thesaurus ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
Neutrophils date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C12533 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0200633 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Platelets
Item
Peripheral Platelet count done
boolean
C38148 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0005821 (UMLS CUI-1)
Platelets
Item
Peripheral Platelet count (mm3)
float
C20200 (NCI Thesaurus Property)
C0005821 (UMLS CUI-1)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
Platelets date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0005821 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Hemoglobin
Item
Hemoglobin done
boolean
C38148 (NCI Thesaurus ValueDomain)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0019046 (UMLS CUI-1)
Hemoglobin
Item
Hemoglobin
float
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0019046 (UMLS CUI-1)
Hemoglobin Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0019046 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Item Group
Adverse Events - Section 3
CTC Adverse Event Term
Item
CTC Adverse Event Term
text
C25284 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C45559 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C2826934 (UMLS CUI-2)
CTC Adverse Event Reported Term
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C2699044 (UMLS CUI-2)
Adverse Event Onset Date
Item
Adverse Event Onset Date
date
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C49704 (NCI Thesaurus ObjectClass)
C25279 (NCI Thesaurus Property)
C2985916 (UMLS CUI-1)
Item
AE Present Status
text
C25626 (NCI Thesaurus Property)
C41331 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C1705586 (UMLS CUI-1)
Code List
AE Present Status
CL Item
Fatal Or Died (Fatal/Died)
CL Item
Intervention For Adverse Event Continues (Intervention for AE Continues)
CL Item
Not Recovered Or Not Resolved (Not recovered/Not resolved)
C49494 (NCI Thesaurus)
C1709277 (UMLS 2011AA)
CL Item
Recovered Or Resolved With Sequelae (Recovered/Resolved with Sequelae)
C49495 (NCI Thesaurus)
C1709862 (UMLS 2011AA)
CL Item
Recovered Or Resolved Without Sequelae (Recovered/Resolved without Sequelae)
C85257 (NCI Thesaurus)
C2827606 (UMLS 2011AA)
CL Item
Recovering Or Resolving (Recovering/Resolving)
C49496 (NCI Thesaurus)
C1709864 (UMLS 2011AA)
Item
The CTCAE data entered above is
text
C25284 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C0333052 (UMLS CUI-2)
Code List
The CTCAE data entered above is
CL Item
Version 2 (version 2)
CL Item
Version 3 (version 3)

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