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7897

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Unknown Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=109F4E7D-3810-226A-E044-0003BA3F9857

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=109F4E7D-3810-226A-E044-0003BA3F9857

Nyckelord

Versioner (4)
  1. 2014-12-18 2014-12-18 - Martin Dugas
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-06-16 2015-06-16 -
  4. 2021-09-20 2021-09-20 -
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9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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    On-Study - Unknown ECOG Lung Onstudy - 2468160v1.0

    Engelsk

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

    1 Formulär  
    Header
    Beskrivning

    Header

    ECOG Protocol Number
    Beskrivning

    Protocol Number ECOG

    Datatyp

    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
    Beskrivning

    Patient ID ECOG

    Datatyp

    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
    Beskrivning

    Generic drug form

    Datatyp

    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
    Beskrivning

    Registration Number

    Datatyp

    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
    Beskrivning

    Clinical Trial Period

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2347804
    NCI Thesaurus ObjectClass
    C25214
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass-2
    C25651
    Unnamed2
    Beskrivning

    Unnamed2

    Patient Initials (Last, First)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    ECOG Protocol Number
    Beskrivning

    Protocol Number ECOG

    Datatyp

    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
    Beskrivning

    Patient ID ECOG

    Datatyp

    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
    Participating Group Protocol Number
    Beskrivning

    Study Number Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Patient ID
    Beskrivning

    Trial subject ID Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Institution/Affiliate
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Unnamed 3
    Beskrivning

    Unnamed 3

    Please mark an 'X' if data have been amended (Please circle amended items in red)
    Beskrivning

    Data amended

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Date data amended (M D Y)
    Beskrivning

    Data amended date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property
    C25416
    NCI Thesaurus ValueDomain-2
    C25367
    Unnamed3
    Beskrivning

    Unnamed3

    ECOG Performance Status
    Beskrivning

    ECOG Performance Status

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C1520224
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain-2
    C25491
    NCI Thesaurus ObjectClass
    C20641
    Height (cm)
    Beskrivning

    Patient Height

    Datatyp

    float

    Måttenheter
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS CUI-1
    C0489786
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25347
    cm
    Weight (kg)
    Beskrivning

    Patient Weight

    Datatyp

    float

    Måttenheter
    • Kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS CUI-1
    C0005910
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25208
    Kg
    Weight Loss in Previous Six Months
    Beskrivning

    Weight Loss past six months

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C0043096
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C3828652
    NCI Thesaurus Property
    C3445
    NCI Thesaurus ValueDomain-2
    C25613
    Description Of Disease At Initial Diagnosis
    Beskrivning

    Description Of Disease At Initial Diagnosis

    Date of initial pathologic diagnosis (M D Y)
    Beskrivning

    CancerInitialDiagnosisDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    Histologic Type
    Beskrivning

    Histologic Type

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS CUI-1
    C0449574
    NCI Thesaurus ObjectClass-2
    C12468
    NCI Thesaurus Property
    C25526
    NCI Thesaurus Property-2
    C25161
    NCI Thesaurus ValueDomain
    C25372
    NCI Thesaurus ValueDomain-2
    C25526
    Specify combined/mixed histologic types
    Beskrivning

    LungNeoplasmCombinedMixedHistologyClassificationSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C12468
    UMLS 2011AA ObjectClass-2
    C0024109
    NCI Thesaurus Property
    C25454
    UMLS 2011AA Property
    C0205195
    NCI Thesaurus Property-2
    C25259
    UMLS 2011AA Property-2
    C0205430
    NCI Thesaurus Property-3
    C25526
    UMLS 2011AA Property-3
    C0205462
    NCI Thesaurus Property-4
    C25161
    UMLS 2011AA Property-4
    C0008902
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Specify Other Histologic Type
    Beskrivning

    Histologic Type, other

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C1299220
    NCI Thesaurus ObjectClass
    C3262
    NCI Thesaurus Property
    C25526
    NCI Thesaurus Property-2
    C25161
    Tumor Location Area
    Beskrivning

    TumorLungAreaType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C12468
    UMLS 2011AA Property
    C0024109
    NCI Thesaurus Property-2
    C25244
    UMLS 2011AA Property-2
    C0205146
    Other specify
    Beskrivning

    DiseaseInvolvedSiteSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property-2
    C25547
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    Data Unknown Text
    Beskrivning

    DataUnknownText

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C17998
    UMLS 2011AA Property
    C0439673
    Stage (as determined by surgical evaluation)
    Beskrivning

    Tumor Stage

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS CUI-1
    C1300072
    NCI Thesaurus ObjectClass-2
    C12468
    NCI Thesaurus ValueDomain
    C16899
    NCI Thesaurus Property
    C25523
    Chemotherapy Regimen
    Beskrivning

    ChemotherapyRegimenType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    History Of Disease
    Beskrivning

    History Of Disease

    Resection Type
    Beskrivning

    LungResectionType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C15232
    UMLS 2011AA Property
    C0728940
    Other, specify
    Beskrivning

    LungResectionSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus Property
    C15232
    UMLS 2011AA Property
    C0728940
    Date of Resection
    Beskrivning

    PatientSurgicalResectionDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25698
    NCI Thesaurus Property-2
    C15232
    UMLS 2011AA Property
    C0728940
    Type of Mediastinal Lymph Node Dissection
    Beskrivning

    MediastinalLymphNodePhysicalExaminationType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass-2
    C25310
    UMLS 2011AA ObjectClass-2
    C1522718
    Other, specify
    Beskrivning

    MediastinalLymphNodePhysicalExaminationSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass-2
    C25310
    UMLS 2011AA ObjectClass-2
    C1522718
    Date of Lymph Node Dissection
    Beskrivning

    MediastinalLymphNodePhysicalExaminationDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus ObjectClass-2
    C25310
    UMLS 2011AA ObjectClass-2
    C1522718
    Pre-operative mediastinoscopy
    Beskrivning

    PreoperativeMediastinoscopyPerformedInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16829
    UMLS 2011AA ObjectClass
    C0025065
    NCI Thesaurus ObjectClass-2
    C54732
    UMLS 2011AA ObjectClass-2
    C0445204
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Date (If yes)
    Beskrivning

    PreoperativeMediastinoscopyPerformedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16829
    UMLS 2011AA ObjectClass
    C0025065
    NCI Thesaurus ObjectClass-2
    C54732
    UMLS 2011AA ObjectClass-2
    C0445204
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Involvement
    Beskrivning

    LymphNodeInvolvementType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    NCI Thesaurus Property
    C25547
    Node Levels
    Beskrivning

    LungLymphNodeInvolvementStatus

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12468
    UMLS 2011AA ObjectClass
    C0024109
    NCI Thesaurus ObjectClass-2
    C12745
    UMLS 2011AA ObjectClass-2
    C0024204
    NCI Thesaurus Property
    C25548
    UMLS 2011AA Property
    C1314939
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Does the patient have a history of wound healing complications (Patients must have recovered from any wound healing complications prior to study entry)
    Beskrivning

    PatientWoundComplicationPersonalMedicalHistoryInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3671
    UMLS 2011AA Property
    C0043250
    NCI Thesaurus Property-2
    C2959
    UMLS 2011AA Property-2
    C0009566
    NCI Thesaurus Property-3
    C18772
    UMLS 2011AA Property-3
    C0262926
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify (If yes:)
    Beskrivning

    PatientWoundComplicationPersonalMedicalHistorySpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3671
    UMLS 2011AA Property
    C0043250
    NCI Thesaurus Property-2
    C2959
    UMLS 2011AA Property-2
    C0009566
    NCI Thesaurus Property-3
    C18772
    UMLS 2011AA Property-3
    C0262926
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Recovery or Latest Date (last known date of disease activity - M D Y)
    Beskrivning

    AdverseEventMostRecentRecoveryDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C41331
    UMLS 2011AA ObjectClass
    C0877248
    NCI Thesaurus Property
    C25746
    UMLS 2011AA Property
    C2004454
    NCI Thesaurus Property-2
    C25577
    UMLS 2011AA Property-2
    C1513491
    Baseline Abnormalities
    Beskrivning

    Baseline Abnormalities

    CTC Adverse Event Term Type (include subterm if applicable Use CTCAE v3 terminology)
    Beskrivning

    CTC Adverse Event Term

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C1516728
    NCI Thesaurus ObjectClass
    C49704
    UMLS CUI-2
    C2826934
    NCI Thesaurus Property
    C45559
    CTC Adverse Event Grade (Use grade 1-4 per CTCAE v3)
    Beskrivning

    CTC Adverse Event Grade

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS CUI-1
    C2985911
    NCI Thesaurus ValueDomain
    C18000
    NCI Thesaurus Property
    C25365
    Comments
    Beskrivning

    Comments

    Investigator Signature
    Beskrivning

    Investigator Signature

    Datatyp

    text

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

    Investigator Signature Date

    Datatyp

    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
    Tillbaka till toppen

    Similar models

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

    1 Formulär
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    Item Group
    Unnamed2
    Patient Initials
    Item
    Patient Initials (Last, First)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    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)
    Study Number Participating Group
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Item Group
    Unnamed 3
    Data amended
    Item
    Please mark an 'X' if data have been amended (Please circle amended items in red)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Data amended date
    Item
    Date data amended (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    ECOG Performance Status
    text
    C25664 (NCI Thesaurus ValueDomain)
    C1520224 (UMLS CUI-1)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain-2)
    C20641 (NCI Thesaurus ObjectClass)
    CL.2
    Code List
    ECOG Performance Status
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    Patient Height
    Item
    Height (cm)
    float
    C25209 (NCI Thesaurus ValueDomain)
    C0489786 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25347 (NCI Thesaurus Property)
    Patient Weight
    Item
    Weight (kg)
    float
    C25209 (NCI Thesaurus ValueDomain)
    C0005910 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25208 (NCI Thesaurus Property)
    Item
    Weight Loss in Previous Six Months
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0043096 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C3828652 (UMLS CUI-2)
    C3445 (NCI Thesaurus Property)
    C25613 (NCI Thesaurus ValueDomain-2)
    CL.3
    Code List
    Weight Loss in Previous Six Months
    CL Item
    <5% Of Body Weight (<5% of body weight)
    CL Item
    5 To <10% Of Body Weight (5 to < 10% of body weight)
    CL Item
    10 To <20% Of Body Weight (10 -<20% of body weight)
    CL Item
    > Or = 20% Of Body Weight (> or = 20% of body weight)
    Item Group
    Description Of Disease At Initial Diagnosis
    CancerInitialDiagnosisDate
    Item
    Date of initial pathologic diagnosis (M D Y)
    date
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    Histologic Type
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0449574 (UMLS CUI-1)
    C12468 (NCI Thesaurus ObjectClass-2)
    C25526 (NCI Thesaurus Property)
    C25161 (NCI Thesaurus Property-2)
    C25372 (NCI Thesaurus ValueDomain)
    C25526 (NCI Thesaurus ValueDomain-2)
    CL.4
    Code List
    Histologic Type
    CL Item
    Squamous Cell Carcinoma (Squamous cell carcinoma)
    C2929 (NCI Thesaurus)
    C0007137 (UMLS 2011AA)
    CL Item
    Adenocarcinoma (Adenocarcinoma)
    C2852 (NCI Thesaurus)
    C0001418 (UMLS 2011AA)
    CL Item
    Large Cell Carcinoma (Large cell carcinoma)
    C3780 (NCI Thesaurus)
    C0206704 (UMLS 2011AA)
    CL Item
    Bronchoalveolar (bac) (Bronchoalveolar carcinoma (BAC))
    CL Item
    Non-small Cell Lung Cancer (nsclc), Nos (Non-small cell lung cancer NOS)
    CL Item
    Combined/mixed, Specify Subcategories (Combined/mixed)
    CL Item
    Other (Other specify)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    C17649 (NCI Thesaurus-3)
    C0205394 (UMLS 2011AA-4)
    LungNeoplasmCombinedMixedHistologyClassificationSpecify
    Item
    Specify combined/mixed histologic types
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus ObjectClass-2)
    C0024109 (UMLS 2011AA ObjectClass-2)
    C25454 (NCI Thesaurus Property)
    C0205195 (UMLS 2011AA Property)
    C25259 (NCI Thesaurus Property-2)
    C0205430 (UMLS 2011AA Property-2)
    C25526 (NCI Thesaurus Property-3)
    C0205462 (UMLS 2011AA Property-3)
    C25161 (NCI Thesaurus Property-4)
    C0008902 (UMLS 2011AA Property-4)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Histologic Type, other
    Item
    Specify Other Histologic Type
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1299220 (UMLS CUI-1)
    C3262 (NCI Thesaurus ObjectClass)
    C25526 (NCI Thesaurus Property)
    C25161 (NCI Thesaurus Property-2)
    Item
    Tumor Location Area
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C12468 (NCI Thesaurus Property)
    C0024109 (UMLS 2011AA Property)
    C25244 (NCI Thesaurus Property-2)
    C0205146 (UMLS 2011AA Property-2)
    CL.5
    Code List
    Tumor Location Area
    CL Item
    Upper Lobe (right) (Upper Lobe (right))
    CL Item
    Middle Lobe (right) (Middle Lobe (right))
    CL Item
    Lower Lobe (right) (Lower Lobe (right))
    CL Item
    Upper Lobe (left) (Upper Lobe (left))
    CL Item
    Lingula (Lingula)
    CL Item
    Lower Lobe (left) (Lower Lobe (left))
    CL Item
    Other, Specify (Other)
    DiseaseInvolvedSiteSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25547 (NCI Thesaurus Property-2)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    DataUnknownText
    Item
    Data Unknown Text
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C17998 (NCI Thesaurus Property)
    C0439673 (UMLS 2011AA Property)
    Item
    Stage (as determined by surgical evaluation)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C1300072 (UMLS CUI-1)
    C12468 (NCI Thesaurus ObjectClass-2)
    C16899 (NCI Thesaurus ValueDomain)
    C25523 (NCI Thesaurus Property)
    CL.6
    Code List
    Stage (as determined by surgical evaluation)
    CL Item
    Ib- T2n0 (IB- T2N0)
    CL Item
    Iia- T1n1 (IIA- T1N1)
    CL Item
    Iib- T2n1 (IIB- T2N1)
    CL Item
    Iib- T3n0 (IIB- T3N0)
    CL Item
    Iiia- T1n2 (IIIA- T1N2)
    CL Item
    Iiia- T2n2 (IIIA- T2N2)
    CL Item
    Iiia- T3n1 (IIIA- T3N1)
    CL Item
    Iiia- T3n2 (IIIA- T3N2)
    Item
    Chemotherapy Regimen
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    CL.7
    Code List
    Chemotherapy Regimen
    CL Item
    Carboplatin And Paclitaxel (Carboplatin and Paclitaxel)
    CL Item
    Cisplatin And Vinorelbine (Cisplatin and Vinorelbine)
    CL Item
    Cisplatin And Docetaxel (Cisplatin and Docetaxel)
    CL Item
    Cisplatin And Gemcitabine (Cisplatin and Gemcitabine)
    Item Group
    History Of Disease
    Item
    Resection Type
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C15232 (NCI Thesaurus Property)
    C0728940 (UMLS 2011AA Property)
    CL.8
    Code List
    Resection Type
    CL Item
    Intrapericardial Pneumonectomy (Intrapericardial pneumonectomy)
    CL Item
    Pneumonectomy (Pneumonectomy)
    C15305 (NCI Thesaurus)
    C0032284 (UMLS 2011AA)
    CL Item
    Lobectomy (Lobectomy)
    C15272 (NCI Thesaurus)
    C0023928 (UMLS 2011AA)
    CL Item
    Bilobectomy (Bilobectomy)
    CL Item
    Sleeve Lobectomy (Sleeve lobectomy)
    CL Item
    Lobectomy And Chest Wall Resection (Lobectomy and chest wall resection)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    LungResectionSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C15232 (NCI Thesaurus Property)
    C0728940 (UMLS 2011AA Property)
    PatientSurgicalResectionDate
    Item
    Date of Resection
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25698 (NCI Thesaurus Property)
    C15232 (NCI Thesaurus Property-2)
    C0728940 (UMLS 2011AA Property)
    Item
    Type of Mediastinal Lymph Node Dissection
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass-2)
    C1522718 (UMLS 2011AA ObjectClass-2)
    CL.9
    Code List
    Type of Mediastinal Lymph Node Dissection
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    Incomplete Sampling (Incomplete sampling)
    CL Item
    Systematic Sampling (Systematic sampling)
    CL Item
    Complete Mediastinal Lymph Node Dissection (Complete mediastinal lymph node dissection)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    MediastinalLymphNodePhysicalExaminationSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass-2)
    C1522718 (UMLS 2011AA ObjectClass-2)
    MediastinalLymphNodePhysicalExaminationDate
    Item
    Date of Lymph Node Dissection
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25310 (NCI Thesaurus ObjectClass-2)
    C1522718 (UMLS 2011AA ObjectClass-2)
    PreoperativeMediastinoscopyPerformedInd-2
    Item
    Pre-operative mediastinoscopy
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16829 (NCI Thesaurus ObjectClass)
    C0025065 (UMLS 2011AA ObjectClass)
    C54732 (NCI Thesaurus ObjectClass-2)
    C0445204 (UMLS 2011AA ObjectClass-2)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    PreoperativeMediastinoscopyPerformedDate
    Item
    Date (If yes)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16829 (NCI Thesaurus ObjectClass)
    C0025065 (UMLS 2011AA ObjectClass)
    C54732 (NCI Thesaurus ObjectClass-2)
    C0445204 (UMLS 2011AA ObjectClass-2)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item
    Involvement
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    C25547 (NCI Thesaurus Property)
    CL.11
    Code List
    Involvement
    CL Item
    Negative (negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Unknown (unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Node Levels
    text
    C12468 (NCI Thesaurus ObjectClass)
    C0024109 (UMLS 2011AA ObjectClass)
    C12745 (NCI Thesaurus ObjectClass-2)
    C0024204 (UMLS 2011AA ObjectClass-2)
    C25548 (NCI Thesaurus Property)
    C1314939 (UMLS 2011AA Property)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.12
    Code List
    Node Levels
    CL Item
    2r (2R)
    CL Item
    4r (4R)
    CL Item
    10r (10R)
    CL Item
    11r (11R)
    CL Item
    12-13r (12-13R)
    CL Item
    1 (1)
    CL Item
    3 (3)
    CL Item
    5 (5)
    CL Item
    6 (6)
    CL Item
    7 (7)
    CL Item
    2l (2L)
    CL Item
    10l (10L)
    CL Item
    11l (11L)
    CL Item
    12-13l (12-13L)
    PatientWoundComplicationPersonalMedicalHistoryInd-2
    Item
    Does the patient have a history of wound healing complications (Patients must have recovered from any wound healing complications prior to study entry)
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3671 (NCI Thesaurus Property)
    C0043250 (UMLS 2011AA Property)
    C2959 (NCI Thesaurus Property-2)
    C0009566 (UMLS 2011AA Property-2)
    C18772 (NCI Thesaurus Property-3)
    C0262926 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientWoundComplicationPersonalMedicalHistorySpecify
    Item
    Specify (If yes:)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3671 (NCI Thesaurus Property)
    C0043250 (UMLS 2011AA Property)
    C2959 (NCI Thesaurus Property-2)
    C0009566 (UMLS 2011AA Property-2)
    C18772 (NCI Thesaurus Property-3)
    C0262926 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    AdverseEventMostRecentRecoveryDate
    Item
    Recovery or Latest Date (last known date of disease activity - M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus ObjectClass)
    C0877248 (UMLS 2011AA ObjectClass)
    C25746 (NCI Thesaurus Property)
    C2004454 (UMLS 2011AA Property)
    C25577 (NCI Thesaurus Property-2)
    C1513491 (UMLS 2011AA Property-2)
    Item Group
    Baseline Abnormalities
    CTC Adverse Event Term
    Item
    CTC Adverse Event Term Type (include subterm if applicable Use CTCAE v3 terminology)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C1516728 (UMLS CUI-1)
    C49704 (NCI Thesaurus ObjectClass)
    C2826934 (UMLS CUI-2)
    C45559 (NCI Thesaurus Property)
    CTC Adverse Event Grade
    Item
    CTC Adverse Event Grade (Use grade 1-4 per CTCAE v3)
    float
    C49704 (NCI Thesaurus ObjectClass)
    C2985911 (UMLS CUI-1)
    C18000 (NCI Thesaurus ValueDomain)
    C25365 (NCI Thesaurus Property)
    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)
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