ID

11051

Description

PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0618400D-589D-7445-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0618400D-589D-7445-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/20/12 9/20/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/16/15 6/16/15 -
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June 16, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision

English

No Instruction available.

1 forms  
  1. StudyEvent: Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision
    1. No Instruction available.
Header
Description

Header

ECOG Protocol Number
Description

Protocol Number ECOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
ECOG Patient ID
Description

Patient ID ECOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1512162
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25491
DCI Name
Description

Generic drug form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C3242750
NCI Thesaurus Property
C19464
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus ObjectClass-2
C25452
Registration Step
Description

Registration Number

Data type

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
Reporting Period
Description

Clinical Trial Period

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2347804
NCI Thesaurus ObjectClass
C25214
NCI Thesaurus Property
C25616
NCI Thesaurus ObjectClass-2
C25651
Second primary cancer assessment
Description

Second primary cancer assessment

Date of Diagnosis of Second Primary Cancer (mm/dd/yyyy)
Description

Second Primary Tumor Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C3262
UMLS CUI-1
C0751623
NCI Thesaurus ObjectClass-2
C25251
UMLS CUI-2
C0011008
NCI Thesaurus ObjectClass-3
C25666
NCI Thesaurus Property
C15220
NCI Thesaurus ValueDomain
C25164
Site of Second Primary Cancer
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25666
UMLS 2011AA ObjectClass-3
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25421
UMLS 2011AA Property-2
C0002808
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Specify
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25666
UMLS 2011AA ObjectClass-3
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25421
UMLS 2011AA Property-2
C0002808
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Include information on histologic subtype (s Please attach copies of any corroborating pathology reports.)
Description

SecondTumorHistologicSubtypeSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C25666
UMLS 2011AA ObjectClass-2
C0205436
NCI Thesaurus Property
C25526
UMLS 2011AA Property
C0205462
NCI Thesaurus Property-2
C25696
UMLS 2011AA Property-2
C0449560
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Comments
Description

Comments

Investigator Signature
Description

Investigator Signature

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
Investigator Signature Date
Description

Investigator Signature Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
UMLS CUI-2
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
Comments
Description

Comments

Data type

text

Alias
UMLS CUI-1
C0947611
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No Instruction available.

1 forms
  1. StudyEvent: Breast Cancer - PACCT-1 TAILORx Second Primary Form - Omitted for 1/5/2011 revision
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Generic drug form
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-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)
Item
Reporting Period
text
C25284 (NCI Thesaurus ValueDomain)
C2347804 (UMLS CUI-1)
C25214 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus ObjectClass-2)
CL.1
Code List
Reporting Period
CL Item
Second Primary Cancer (Second primary)
Item Group
Second primary cancer assessment
Second Primary Tumor Date
Item
Date of Diagnosis of Second Primary Cancer (mm/dd/yyyy)
date
C3262 (NCI Thesaurus ObjectClass)
C0751623 (UMLS CUI-1)
C25251 (NCI Thesaurus ObjectClass-2)
C0011008 (UMLS CUI-2)
C25666 (NCI Thesaurus ObjectClass-3)
C15220 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C0205436 (UMLS 2011AA ObjectClass-3)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property-2)
C0002808 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Site of Second Primary Cancer
CL Item
Acute Lymphocytic Leukemia (Acute Lymphocytic Leukemia (ALL))
CL Item
Acute Myelogenous Leukemia (Acute Myelogenous Leukemia (AML))
CL Item
Adrenal (Adrenal)
CL Item
Aids-related Lymphoma (AIDS-related Lymphoma)
CL Item
Anal Canal (Anal Canal)
C12375 (NCI Thesaurus)
C0227411 (UMLS 2011AA)
CL Item
Basal Cell Carcinoma (Basal Cell Carcinoma)
CL066969 (NCI Metathesaurus)
CL Item
Bladder, Urinary Tract (Bladder, Urinary Tract)
CL Item
Brain Tumor (Brain Tumor)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Breast, In Situ (Breast, in situ)
CL Item
Carcinoid (Carcinoid)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Chronic Lymphocytic Leukemia (Chronic Lymphocytic Leukemia (CLL))
CL Item
Chronic Myelogenous Leukemia (Chronic Myelogenous Leukemia (CML))
C3174 (NCI Thesaurus)
C0023473 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Endometrium, Uterine Corpus (Endometrium, Uterine Corpus)
CL Item
Esophagus (Esophagus)
C12389 (NCI Thesaurus)
C0014876 (UMLS 2011AA)
CL Item
Gastric Cancer (Gastric Cancer)
CL Item
Hairy Cell Leukemia (Hairy Cell Leukemia)
C7402 (NCI Thesaurus)
C0023443 (UMLS 2011AA)
CL Item
Head And Neck (Head and Neck)
C12418 (NCI Thesaurus)
C0460004 (UMLS 2011AA)
CL Item
Hodgkin's Lymphoma (Hodgkin's Disease)
C9357 (NCI Thesaurus)
C0019829 (UMLS 2011AA)
CL Item
Islet Cell/carcinoid (Islet Cell/Carcinoid)
CL Item
Kaposi Sarcoma (Kaposi sarcoma)
C9087 (NCI Thesaurus)
C0036220 (UMLS 2011AA)
CL Item
Leukemia (Leukemia)
C3161 (NCI Thesaurus)
C0023418 (UMLS 2011AA)
CL Item
Liver, Gall Bladder, Bile Duct (Liver, Gall Bladder, Bile Duct)
CL Item
Lung Cancer (Lung cancer)
CL Item
Lymphoma (Lymphoma)
C3208 (NCI Thesaurus)
C0024299 (UMLS 2011AA)
CL Item
Lymphosarcoma (Lymphosarcoma)
CL Item
Melanoma (Melanoma)
C3224 (NCI Thesaurus)
C0025202 (UMLS 2011AA)
CL Item
Mesothelioma (Mesothelioma)
CL Item
Myelodysplastic Syndrome (Myelodysplastic Syndrome)
CL Item
Myeloma (Myeloma)
CL Item
Non-hodgkin's Lymphoma (Non-Hodgkin's Lymphoma)
C3211 (NCI Thesaurus)
C0024305 (UMLS 2011AA)
CL Item
Non-small Cell Lung Cancer (Non-Small Cell Lung Cancer)
CL Item
Osteosarcoma (Osteosarcoma)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Other Gyn (Other GYN)
CL Item
Other Non-melanoma Skin Cancer (Other non-melanoma skin cancer)
CL Item
Ovarian (Ovarian)
CL Item
Pancreas (Pancreas)
C12393 (NCI Thesaurus)
C0030274 (UMLS 2011AA)
CL Item
Penile (Penile)
CL Item
Pleural Effusion (Pleural effusion)
C3331 (NCI Thesaurus)
C0021071 (UMLS 2011AA)
CL Item
Promyelocytic Leukemia (Promyelocytic Leukemia (APL))
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Rectum (Rectum)
C12390 (NCI Thesaurus)
C0034896 (UMLS 2011AA)
CL Item
Renal Cell (Renal Cell)
CL Item
Sarcoma (Sarcoma)
C9118 (NCI Thesaurus)
C1261473 (UMLS 2011AA)
CL Item
Small Intestine (Small Intestine)
C12386 (NCI Thesaurus)
C0021852 (UMLS 2011AA)
CL Item
Small-cell Lung Cancer (Small-Cell Lung Cancer)
CL Item
Spinal Cord (Spinal Cord)
C12464 (NCI Thesaurus)
C0037925 (UMLS 2011AA)
CL Item
Testis, Germ Cell, Seminoma (Testis, Germ Cell, Seminoma)
CL Item
Thymoma (Thymoma)
CL Item
Thyroid (Thyroid)
CL Item
Waldenstrom's Macroglobulinemia (Waldenstrom's Macroglobulinemia)
SecondPrimaryMalignantNeoplasmAnatomicSiteSpecify
Item
Specify
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C0205436 (UMLS 2011AA ObjectClass-3)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property-2)
C0002808 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
SecondTumorHistologicSubtypeSpecify
Item
Include information on histologic subtype (s Please attach copies of any corroborating pathology reports.)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass-2)
C0205436 (UMLS 2011AA ObjectClass-2)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25696 (NCI Thesaurus Property-2)
C0449560 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Comments
Investigator Signature
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
Comments
Item
Comments
text
C0947611 (UMLS CUI-1)
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