ID

790

Beschreibung

CALGB: 49907 ADJUVANT TREATMENT SUMMARY FORM; All Patients Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D76F4-2138-330D-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D76F4-2138-330D-E034-080020C9C0E0

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 22.04.15 22.04.15 - Martin Dugas
Hochgeladen am

26. August 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102 Treatment - CALGB: 49907 ADJUVANT TREATMENT SUMMARY FORM; All Patients - 2042891v3.0

Englisch

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.

1 Formulare  
Unnamed1
Beschreibung

Unnamed1

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

First date protocol therapy was given
Beschreibung

TreatmentBeginDate

Datentyp

date

Last date protocol therapy was given (M)
Beschreibung

ProtocolTreatmentAdministeredEndDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Amended data?
Beschreibung

Amendeddata?

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschreibung

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Adjunct

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientNo.

Datentyp

text

Treatment Cycle Information
Beschreibung

Treatment Cycle Information

Total Dose of Drugs for Cycle 1 (mg)
Beschreibung

TotalDoseofDrugsforCycle1

Datentyp

double

Agent Name
Beschreibung

AgentName

Datentyp

text

Reason Treatment Ended (mark one with an X)
Beschreibung

ReasonTreatmentEnded

Datentyp

text

Other, specify (reason treatment ended)
Beschreibung

Other,specify(reasontreatmentended)

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

First Date (Treatment Schedule - Systemic Therapy)
Beschreibung

FirstDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25509
UMLS 2011AA ValueDomain
C1279901
Unnamed4
Beschreibung

Unnamed4

Were there any dose modifications or additions/ omissions to protocol treatment? (Treatment Schedule - Other Therapy)
Beschreibung

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatment?

Datentyp

text

Were any optional protocol therapies given?
Beschreibung

Wereanyoptionalprotocoltherapiesgiven?

Datentyp

text

optional protocol therapy name(s)
Beschreibung

optionalprotocoltherapyname(s)

Datentyp

text

Was any concurrent non-protocol therapy given during protocol treatment?
Beschreibung

Wasanyconcurrentnon-protocoltherapygivenduringprotocoltreatment?

Datentyp

text

indicate below (concurrent non-protocol therapy given during protocol treatment) (mark all that apply with an X)
Beschreibung

indicatebelow(concurrentnon-protocoltherapygivenduringprotocoltreatment)

Datentyp

text

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Unnamed5
Beschreibung

Unnamed5

Completed By (Print or Type Name)
Beschreibung

CompletedBy

Datentyp

text

Date Completed
Beschreibung

DateCompleted

Datentyp

date

Ccrr Module For Calgb: 49907 Adjuvant Treatment Summary Form; All Patients
Beschreibung

Ccrr Module For Calgb: 49907 Adjuvant Treatment Summary Form; All Patients

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Ähnliche Modelle

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.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
TreatmentBeginDate
Item
First date protocol therapy was given
date
ProtocolTreatmentAdministeredEndDate
Item
Last date protocol therapy was given (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Treatment Cycle Information
TotalDoseofDrugsforCycle1
Item
Total Dose of Drugs for Cycle 1 (mg)
double
Item
Agent Name
text
CL.2
Code List
Agent Name
CL Item
Cyclophosphamide (Cyclophosphamide)
C405 (NCI Thesaurus)
C0010583 (UMLS 2011AA)
CL Item
Methotrexate (Methotrexate)
C642 (NCI Thesaurus)
C0025677 (UMLS 2011AA)
CL Item
Fluorouracil (Fluorouracil)
C505 (NCI Thesaurus)
C0016360 (UMLS 2011AA)
CL Item
Adriamycin (Adriamycin)
CL Item
Capecitabine (Capecitabine)
C1794 (NCI Thesaurus)
C0671970 (UMLS 2011AA)
Item
Reason Treatment Ended (mark one with an X)
text
CL.3
Code List
Reason Treatment Ended (mark one with an X)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression/relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Death On Study (Death on study)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Other Complicating Disease (Other complicating disease)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Other, Specify: (Other, specify)
Other,specify(reasontreatmentended)
Item
Other, specify (reason treatment ended)
text
Item Group
Unnamed3
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
FirstDate
Item
First Date (Treatment Schedule - Systemic Therapy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain)
C1279901 (UMLS 2011AA ValueDomain)
Item Group
Unnamed4
Item
Were there any dose modifications or additions/ omissions to protocol treatment? (Treatment Schedule - Other Therapy)
text
CL.4
Code List
Were there any dose modifications or additions/ omissions to protocol treatment? (Treatment Schedule - Other Therapy)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Planned (Yes, planned)
CL Item
Yes, Unplanned (Yes, unplanned)
CL Item
Unknown (Unknown)
Item
Were any optional protocol therapies given?
text
CL.5
Code List
Were any optional protocol therapies given?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
optionalprotocoltherapyname(s)
Item
optional protocol therapy name(s)
text
Item
Was any concurrent non-protocol therapy given during protocol treatment?
text
CL.6
Code List
Was any concurrent non-protocol therapy given during protocol treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
indicate below (concurrent non-protocol therapy given during protocol treatment) (mark all that apply with an X)
text
CL.7
Code List
indicate below (concurrent non-protocol therapy given during protocol treatment) (mark all that apply with an X)
CL Item
Concurrent Non-protocol Chemotherapy (Concurrent non-protocol chemotherapy)
CL Item
Concurrent Non-protocol Hormonal Therapy (Concurrent non-protocol hormonal therapy)
CL Item
Concurrent Non-protocol Biologic Response Modifier Therapy (Concurrent non-protocol biologic response modifier therapy)
CL Item
Concurrent Non-protocol Radiation Therapy (Concurrent non-protocol radiation therapy)
CL Item
Concurrent Non-protocol High Dose Chemotherapy/autologous Stem Cell Transplant (Concurrent non-protocol high dose chemotherapy/ autologous stem cell transplant)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Unnamed5
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date
Item Group
Ccrr Module For Calgb: 49907 Adjuvant Treatment Summary Form; All Patients
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