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Informatie:
Fout:
ID
801
Beschrijving
CALGB: 40101 TREATMENT SUMMARY SUBSET FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0
Link
Trefwoorden
Versies (2)
- 26-08-12 26-08-12 -
- 24-04-15 24-04-15 - Martin Dugas
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26 augustus 2012
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00041119 Treatment - CALGB: 40101 TREATMENT SUMMARY SUBSET FORM - 2037407v3.0
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 Statistical Center, Data Operations. 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.
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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 Statistical Center, Data Operations. 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.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
CourseBeginDate
Item
Cycle start date
date
Cycleenddate
Item
Cycle end date (M)
text
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
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
Currentcyclenumber
Item
Current cycle number
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
BSA
Item
BSA
text
Totaldosageforthiscycle,Doxorubicin
Item
Total dosage for this cycle, Doxorubicin (mg)
text
Totaldosageforthiscycle,Cyclophosphamide
Item
Total dosage for this cycle, Cyclophosphamide (mg)
text
Totaldosageforthiscycle,Paclitaxel
Item
Total dosage for this cycle, Paclitaxel (mg)
text
CL Item
Reduced (Reduced)
C25640 (NCI Thesaurus)
C0392756 (UMLS 2011AA)
C0392756 (UMLS 2011AA)
CL Item
Delayed (Delayed)
C25477 (NCI Thesaurus)
CL Item
Reduced And Delayed (Reduced and delayed)
CL Item
Not Satisfactorily Recovered From Hematologic Toxicity (Not satisfactorily recovered from hematologic toxicity)
CL Item
Grade 3 Or 4 Fatigue (Grade 3 or 4 fatigue)
CL Item
Grade 2 Or 3 Anaphylaxis/hypersensitivity (Grade 2 or 3 anaphylaxis/hypersensitivity)
CL Item
Grade 3 Or 4 Diarrhea/nausea (Grade 3 or 4 diarrhea/nausea)
CL Item
Grade 3 Or 4 Mucositis (Grade 3 or 4 mucositis)
CL Item
Grade 2 Or Higher Neuropathy (Grade 2 or higher neuropathy)
CL Item
Grade 3 Or Higher Cardiac Toxicity (Grade 3 or higher cardiac toxicity)
CL Item
Grade 3 Or Higher Infection (Grade 3 or higher infection)
CL Item
Grade 3 Or 4 Other Non-hematologic Toxicity (Grade 3 or 4 other non-hematologic toxicity)
CL Item
Holiday/vacation (Holiday/vacation)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
Specify(reasonforadjustment)
Item
Specify (reason for adjustment) (if applicable)
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date