ID

779

Beschreibung

Southwest Oncology Group Ovarian Function Assessment (S0230) Goserelin in Preventing Ovarian Failure in Women Receiving Chemotherapy for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA6A9CC-6D74-0D93-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BEA6A9CC-6D74-0D93-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

26. August 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00068601 Pre-Study - Southwest Oncology Group Ovarian Function Assessment (S0230) - 2170708v3.0

Englisch

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section.

1 Formulare  
Menstrual Cycle
Beschreibung

Menstrual Cycle

First day of the most current or most recent menstrual cycle
Beschreibung

Firstdayoflastmenstrualperiod

Datentyp

text

Have the patient's menstrual periods been absent for the entire preceding 6 months?
Beschreibung

Havethepatient'smenstrualperiodsbeenabsentfortheentirepreceding6months?

Datentyp

text

If no, have the patient's menstrual periods been absent for the entire preceding 3 months?
Beschreibung

Ifno,havethepatient'smenstrualperiodsbeenabsentfortheentirepreceding3months?

Datentyp

text

Laboratory Test
Beschreibung

Laboratory Test

Laboratory lower limit for postmenopausal FSH
Beschreibung

LaboratoryProcedureFollicleStimulatingHormoneResultLowerLimitofNormalValue

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property
C2286
UMLS 2011AA Property
C0733758
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain
C25555
UMLS 2011AA ValueDomain
C1518030
Laboratory upper limit for postmenopausal estradiol
Beschreibung

Laboratoryupperlimitforpostmenopausalestradiol

Datentyp

text

Laboratory upper limit for postmenopausal inhibin B
Beschreibung

LaboratoryupperlimitforpostmenopausalinhibinB

Datentyp

text

FSH level
Beschreibung

FSHvalue

Datentyp

text

FSH date
Beschreibung

LaboratoryProcedureFollicleStimulatingHormoneResultDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C2286
UMLS 2011AA Property
C0733758
Estradiol level
Beschreibung

Estradiolpmol/L

Datentyp

text

Estradiol date
Beschreibung

Dateblooddrawnforthisestradiollevel

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Metathesaurus ObjectClass
C0521425
NCI Thesaurus Property
C2295
UMLS 2011AA Property
C0014912
NCI Thesaurus Property
C37984
UMLS 2011AA Property
C0022877
Inhibin B level
Beschreibung

InhibinBlevel

Datentyp

text

Inhibin B date (For women with Regular Menses)
Beschreibung

InhibinBdate

Datentyp

text

Were these hormone levels measured on days 2, 3, or 4 of the menstrual cycle?
Beschreibung

Werethesehormonelevelsmeasuredondays2,3,or4ofthemenstrualcycle?

Datentyp

text

Specify reason
Beschreibung

Specifyreason

Datentyp

text

Comments
Beschreibung

ResearchCommentsText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Ccrr Module For Southwest Oncology Group Ovarian Function Assessment (s0230)
Beschreibung

Ccrr Module For Southwest Oncology Group Ovarian Function Assessment (s0230)

SWOG Patient ID
Beschreibung

PatientSouthwestOncologyGroupIdentifierNumber

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25699
UMLS 2011AA Property
C1519429
Patient Initials (L, F, M)
Beschreibung

PatientInitialsName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Insitution/Affiliate
Beschreibung

CombinedInstitutionName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Physician
Beschreibung

RegisteredInvestigatorName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
NCI Thesaurus ObjectClass
C25644
Group Name
Beschreibung

ParticipatingGroupName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Group Name
Beschreibung

ParticipatingGroupName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study NO.
Beschreibung

ProtocolParticipatingIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Pt. ID
Beschreibung

PatientParticipatingIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date of Assessment
Beschreibung

LesionAssessmentDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Assessment Time
Beschreibung

TimePeriod

Datentyp

text

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Ähnliche Modelle

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Menstrual Cycle
Firstdayoflastmenstrualperiod
Item
First day of the most current or most recent menstrual cycle
text
Item
Have the patient's menstrual periods been absent for the entire preceding 6 months?
text
CL.1
Code List
Have the patient's menstrual periods been absent for the entire preceding 6 months?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If no, have the patient's menstrual periods been absent for the entire preceding 3 months?
text
CL.2
Code List
If no, have the patient's menstrual periods been absent for the entire preceding 3 months?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Laboratory Test
LaboratoryProcedureFollicleStimulatingHormoneResultLowerLimitofNormalValue
Item
Laboratory lower limit for postmenopausal FSH
double
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C2286 (NCI Thesaurus Property)
C0733758 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain)
C1518030 (UMLS 2011AA ValueDomain)
Laboratoryupperlimitforpostmenopausalestradiol
Item
Laboratory upper limit for postmenopausal estradiol
text
LaboratoryupperlimitforpostmenopausalinhibinB
Item
Laboratory upper limit for postmenopausal inhibin B
text
FSHvalue
Item
FSH level
text
LaboratoryProcedureFollicleStimulatingHormoneResultDate
Item
FSH date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C2286 (NCI Thesaurus Property)
C0733758 (UMLS 2011AA Property)
Estradiolpmol/L
Item
Estradiol level
text
Dateblooddrawnforthisestradiollevel
Item
Estradiol date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0521425 (NCI Metathesaurus ObjectClass)
C2295 (NCI Thesaurus Property)
C0014912 (UMLS 2011AA Property)
C37984 (NCI Thesaurus Property)
C0022877 (UMLS 2011AA Property)
InhibinBlevel
Item
Inhibin B level
text
InhibinBdate
Item
Inhibin B date (For women with Regular Menses)
text
Item
Were these hormone levels measured on days 2, 3, or 4 of the menstrual cycle?
text
CL.3
Code List
Were these hormone levels measured on days 2, 3, or 4 of the menstrual cycle?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Specifyreason
Item
Specify reason
text
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item Group
Ccrr Module For Southwest Oncology Group Ovarian Function Assessment (s0230)
PatientSouthwestOncologyGroupIdentifierNumber
Item
SWOG Patient ID
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus Property)
C1519429 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Insitution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
RegisteredInvestigatorName
Item
Physician
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C25644 (NCI Thesaurus ObjectClass)
ParticipatingGroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipatingGroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Study NO.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Pt. ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
LesionAssessmentDate
Item
Date of Assessment
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item
Assessment Time
text
CL.4
Code List
Assessment Time
CL Item
1 Year (1 Year)
CL Item
2 Year (2 Year)
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