ID

7620

Descrizione

ACOSOG-Z4099 Imaging Report Submission Form Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A01C569D-F032-05E1-E040-BB89AD4349E3

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A01C569D-F032-05E1-E040-BB89AD4349E3

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 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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Lung Cancer NCT01336894 Transmittal - ACOSOG-Z4099 Imaging Report Submission Form - 3220472v1.0

Inglese

ALL ITEMS MUST BE COMPLETED

1 moduli  
  1. StudyEvent: ACOSOG-Z4099 Imaging Report Submission Form
    1. ALL ITEMS MUST BE COMPLETED
Header Module
Descrizione

Header Module

Protocol Number
Descrizione

Protocol ID ACOSOG

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1515944
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C19712
Patient ID
Descrizione

Patient Study ID

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Patient Initials (L F M)
Descrizione

Patient Initials

Tipo di dati

text

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

Institution Number

Tipo di dati

text

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

Institution Name

Tipo di dati

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 (check one if data amended, please circle in red when using paper forms)
Descrizione

Data amended

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Visit
Descrizione

Visit

Visit (check one)
Descrizione

AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C19712
UMLS 2011AA ObjectClass
C1515944
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Method Used For Report Submission
Descrizione

Method Used For Report Submission

Imaging report submitted (check one)
Descrizione

ImagingMethodType

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
Method used for report submission (check one)
Descrizione

Document type, required

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C1547673
NCI Thesaurus ObjectClass
C42651
UMLS CUI-2
C1514873
NCI Thesaurus ObjectClass-2
C19498
NCI Thesaurus Property
C25695
Date Sent (If Surface mail, dd MMM yyyy)
Descrizione

FormSubmissionDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
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Similar models

ALL ITEMS MUST BE COMPLETED

1 moduli
  1. StudyEvent: ACOSOG-Z4099 Imaging Report Submission Form
    1. ALL ITEMS MUST BE COMPLETED
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header Module
Protocol ID ACOSOG
Item
Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1515944 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C19712 (NCI Thesaurus Property-2)
Patient Study ID
Item
Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (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 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 (check one if data amended, please circle in red when using paper forms)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Visit
Item
Visit (check one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19712 (NCI Thesaurus ObjectClass)
C1515944 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
CL.2
Code List
Visit (check one)
CL Item
Registration (Registration)
C25646 (NCI Thesaurus)
C1514821 (UMLS 2011AA)
CL Item
4 Weeks After Surgery (4 weeks after surgery)
CL Item
3 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (3 months after surgery/completion of SBRT)
CL Item
6 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (6 months after surgery/completion of SBRT)
CL Item
9 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (9 months after surgery/completion of SBRT)
CL Item
12 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (12 months after surgery/completion of SBRT)
CL Item
15 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (15 months after surgery/completion of SBRT)
CL Item
18 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (18 months after surgery/completion of SBRT)
CL Item
21 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (21 months after surgery/completion of SBRT)
CL Item
24 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (24 months after surgery/completion of SBRT)
CL Item
30 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (30 months after surgery/completion of SBRT)
CL Item
36 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (36 months after surgery/completion of SBRT)
CL Item
48 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (48 months after surgery/completion of SBRT)
CL Item
60 Months After Surgery/completion Of Stereotactic Body Radiation Therapy (60 months after surgery/completion of SBRT)
CL Item
At Time Of Disease Relapse/pd (At time of disease relapse/PD)
Item Group
Method Used For Report Submission
Item
Imaging report submitted (check one)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
CL.3
Code List
Imaging report submitted (check one)
CL Item
Pet/ct Scan (PET/CT scan)
CL Item
Computed Tomography (CT scan)
C17204 (NCI Thesaurus)
C0040405 (UMLS 2011AA)
CL Item
Both Pet/ct Scan And Ct Scan (Both PET/CT scan and CT scan)
Item
Method used for report submission (check one)
text
C25284 (NCI Thesaurus ValueDomain)
C1547673 (UMLS CUI-1)
C42651 (NCI Thesaurus ObjectClass)
C1514873 (UMLS CUI-2)
C19498 (NCI Thesaurus ObjectClass-2)
C25695 (NCI Thesaurus Property)
CL.4
Code List
Method used for report submission (check one)
CL Item
Electronic Attachment (Electronic attachment)
CL Item
Surface Mail (Surface mail)
FormSubmissionDate
Item
Date Sent (If Surface mail, dd MMM yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
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