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ID

7909

Beschrijving

PACCT-1 TAILORx Source Document Tracking Coversheet Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05D8F2BE-C5D0-4050-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05D8F2BE-C5D0-4050-E044-0003BA3F9857

Trefwoorden

  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    Breast Cancer NCT00310180 Lab - PACCT-1 TAILORx Source Document Tracking Coversheet - 2430791v1.0

    INSTRUCTIONS: Complete this form and attach to any source document to be submitted to ECOG. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

    Header
    Beschrijving

    Header

    ECOG Protocol Number
    Beschrijving

    Protocol Number ECOG

    Datatype

    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
    Beschrijving

    Patient ID ECOG

    Datatype

    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
    Beschrijving

    Generic drug form

    Datatype

    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
    Beschrijving

    Registration Number

    Datatype

    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 (Choose one x)
    Beschrijving

    Clinical Trial Period

    Datatype

    text

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

    Header

    Document type (Choose one x)
    Beschrijving

    Document type, required

    Datatype

    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 of this Report (List the date the source document was created below.)
    Beschrijving

    ReportCreatedDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25375
    UMLS 2011AA ObjectClass
    C0684224
    NCI Thesaurus Property
    C42620
    UMLS 2011AA Property
    C1706214

    Similar models

    INSTRUCTIONS: Complete this form and attach to any source document to be submitted to ECOG. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    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 (Choose one x)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2347804 (UMLS CUI-1)
    C25214 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C25651 (NCI Thesaurus ObjectClass-2)
    Code List
    Reporting Period (Choose one x)
    CL Item
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    CL Item
    Recurrence (Recurrence)
    C3352 (NCI Thesaurus)
    C0034897 (UMLS 2011AA)
    CL Item
    Second Primary Cancer (Second primary)
    CL Item
    Death (Death)
    C28554 (NCI Thesaurus)
    C0011065 (UMLS 2011AA)
    Item Group
    Header
    Item
    Document type (Choose one x)
    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)
    Code List
    Document type (Choose one x)
    CL Item
    Pathology Report (Pathology Report)
    C28277 (NCI Thesaurus)
    C0807321 (UMLS 2011AA)
    CL Item
    Er/pr Report (ER/PR Report)
    CL Item
    Her2/neu Report (Her2/neu Report)
    CL Item
    Surgical Report (Surgical Report)
    CL Item
    Radiology Report (Radiology Report)
    CL Item
    Lab Report (Lab Report)
    CL Item
    Mammogram Report (Mammogram Report)
    CL Item
    Physician Note (Physician Note)
    ReportCreatedDate
    Item
    Date of this Report (List the date the source document was created below.)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25375 (NCI Thesaurus ObjectClass)
    C0684224 (UMLS 2011AA ObjectClass)
    C42620 (NCI Thesaurus Property)
    C1706214 (UMLS 2011AA Property)

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