ID
768
Beskrivning
CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D1CA4-8ADF-4761-E034-0003BA0B1A09
Länk
Nyckelord
Versioner (2)
- 2012-08-26 2012-08-26 -
- 2014-03-20 2014-03-20 - Martin Dugas
Uppladdad den
26 augusti 2012
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053339 Treatment - CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients - 2054479v3.0
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. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, 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 PDF version of the form.
Beskrivning
Unnamed2
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Patient'sName
Datatyp
text
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ParticipatingGroup
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beskrivning
PatientHospitalNumber
Datatyp
text
Beskrivning
ParticipatingGroupProtocolNo.
Datatyp
text
Beskrivning
AffiliateName
Datatyp
text
Beskrivning
ParticipatingGroupPatientID
Datatyp
text
Beskrivning
Treatment Cycle Information
Beskrivning
AgentTotalDose(percourse)
Datatyp
double
Beskrivning
AgentName
Datatyp
text
Beskrivning
OffTreatmentReason
Datatyp
text
Beskrivning
OffTreatmentReason,Other
Datatyp
text
Beskrivning
Treatment Schedule - Systemic Therapy
Beskrivning
Treatment Schedule - Other Therapy
Beskrivning
OptionalProtocolTherapyInd
Datatyp
text
Beskrivning
OptionalProtocolTherapyName
Datatyp
text
Beskrivning
ConcurrentNon-ProtocolTherapyInd
Datatyp
text
Beskrivning
indicatebelow(concurrentnon-protocoltherapygivenduringprotocoltreatment)
Datatyp
text
Beskrivning
Comments
Beskrivning
Unnamed5
Beskrivning
Ccrr Module For Calgb: 49903 Advanced Treatment Summary Form; All Patients
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. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, 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 PDF version of the form.
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)