ID

8021

Beskrivning

GOG Common Toxicity Reporting Form Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B3D1-8528-2473-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B3D1-8528-2473-E034-0003BA12F5E7

Nyckelord

Versioner (2)
  1. 2012-08-27 2012-08-27 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00064077 Toxicity - GOG Common Toxicity Reporting Form - 2059265v3.0

Engelsk

FORM T

1 Formulär  
  1. StudyEvent: GOG Common Toxicity Reporting Form
    1. FORM T
Header Module
Beskrivning

Header Module

Date form originally completed (m d y)
Beskrivning

FormCompletionDate,Original

Datatyp

date

Date form amended (m d y)
Beskrivning

FormCompletionDate,Amended

Datatyp

date

Person amending form, last name
Beskrivning

Person Amending Form

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25190
UMLS CUI-2
C1547383
NCI Thesaurus Property
C25364
Patient Name, Last
Beskrivning

PatientName,Last

Datatyp

text

Patient Name, First
Beskrivning

PatientName,First

Datatyp

text

Patient Study ID
Beskrivning

PatientStudyID

Datatyp

text

Person Completing Form, Last Name
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

Adverse Events - Section 1
Beskrivning

Adverse Events - Section 1

Current course number (The toxicities listed below occurred following this course of therapy)
Beskrivning

Cycle Number Chemotherapeutics

Datatyp

float

Alias
UMLS CUI-1
C2045829
Has the patient received any transfusions during this course of therapy?
Beskrivning

TransfusionInd

Datatyp

text

Was patient hospitalized as a result of reported adverse events?
Beskrivning

InpatientHospitalizationInd

Datatyp

boolean

Were cytokines administered this course?
Beskrivning

Cytokine Therapy

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0199974
NCI Thesaurus Property
C20464
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property-2
C25382
Yes (Cytokines), specify
Beskrivning

AgentCytokineAdministeredSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Has an Adverse Drug Reaction Report been filed?
Beskrivning

ADRFiledInd

Datatyp

boolean

Alias
NCI Thesaurus ObjectClass
C25410
UMLS 2011AA ObjectClass
C1521800
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Adverse Events - Section 2
Beskrivning

Adverse Events - Section 2

Peripheral WBC count, Done
Beskrivning

WBC done

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0023508
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
Peripheral WBC count (1000/mm3 Nadir)
Beskrivning

Lab,Hematology,WBC

Datatyp

float

Peripheral WBC count, Date (m d y)
Beskrivning

Lab,Hematology,WBCDate

Datatyp

date

Peripheral Granulocytes count, Done
Beskrivning

LaboratoryProcedureAbsoluteNeutrophilCountGranulocyteOutcomeInd-3

Datatyp

boolean

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C12530
UMLS 2011AA Property-2
C0018183
NCI Thesaurus Property-3
C63321
UMLS 2011AA Property-3
C0948762
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
Beskrivning

Lab,Hematology,GranulocyteCount

Datatyp

float

Peripheral Granulocytes count, Date
Beskrivning

Lab,Hematology,GranDate

Datatyp

date

Peripheral Platelet count, Done
Beskrivning

Platelets

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0005821
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
Peripheral Platelet count (mm3 Nadir)
Beskrivning

Lab,Hematology,Platelets

Datatyp

float

Peripheral Platelet count, Date
Beskrivning

Lab,Hematology,PlateletDate

Datatyp

date

Hemoglobin, Done
Beskrivning

Hemoglobin

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0019046
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
Hemoglobin (G/DL Nadir)
Beskrivning

Lab,Hematology,Hemoglobin

Datatyp

float

Hemoglobin, Date
Beskrivning

Lab,Hematology,HGBDate

Datatyp

date

CTC Adverse Event Grade
Beskrivning

CTCAdverseEventGrade

Datatyp

text

CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Beskrivning

CTCAdverseEventAttributionCode

Datatyp

text

Adverse Events - Section 3
Beskrivning

Adverse Events - Section 3

CTC Adverse Event Term
Beskrivning

CTCAdverseEventTerm

Datatyp

text

CTC Adverse Event Grade
Beskrivning

CTCAdverseEventGrade

Datatyp

text

CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Beskrivning

CTCAdverseEventAttributionCode

Datatyp

text

Comments
Beskrivning

Comments

COMMENTS
Beskrivning

Comments

Datatyp

text

Footer Module
Beskrivning

Footer Module

Participating Group Code
Beskrivning

ParticipatingGroupCode

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Participating Group Protocol Number
Beskrivning

ParticipatingGroupProtocolNumber

Datatyp

float

Participating Patient Study 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
Ccrr Module For Gog Common Toxicity Reporting Form
Beskrivning

Ccrr Module For Gog Common Toxicity Reporting Form

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Similar models

FORM T

1 Formulär
  1. StudyEvent: GOG Common Toxicity Reporting Form
    1. FORM T
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Header Module
FormCompletionDate,Original
Item
Date form originally completed (m d y)
date
FormCompletionDate,Amended
Item
Date form amended (m d y)
date
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1547383 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientStudyID
Item
Patient Study ID
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
Item Group
Adverse Events - Section 1
Cycle Number Chemotherapeutics
Item
Current course number (The toxicities listed below occurred following this course of therapy)
float
C2045829 (UMLS CUI-1)
Item
Has the patient received any transfusions during this course of therapy?
text
CL.1
Code List
Has the patient received any transfusions during this course of therapy?
CL Item
No Transfusion (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Transfusion With Red Blood Cells (Yes, pRBC)
CL Item
Transfusion With Platelets (Yes, platelets)
InpatientHospitalizationInd
Item
Was patient hospitalized as a result of reported adverse events?
boolean
Item
Were cytokines administered this course?
text
C38148 (NCI Thesaurus ValueDomain)
C0199974 (UMLS CUI-1)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
CL.3
Code List
Were cytokines administered this course?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AgentCytokineAdministeredSpecify
Item
Yes (Cytokines), specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
ADRFiledInd
Item
Has an Adverse Drug Reaction Report been filed?
boolean
C25410 (NCI Thesaurus ObjectClass)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
Item Group
Adverse Events - Section 2
WBC done
Item
Peripheral WBC count, Done
boolean
C38148 (NCI Thesaurus ValueDomain)
C0023508 (UMLS CUI-1)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Lab,Hematology,WBC
Item
Peripheral WBC count (1000/mm3 Nadir)
float
Lab,Hematology,WBCDate
Item
Peripheral WBC count, Date (m d y)
date
LaboratoryProcedureAbsoluteNeutrophilCountGranulocyteOutcomeInd-3
Item
Peripheral Granulocytes count, Done
boolean
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12530 (NCI Thesaurus Property-2)
C0018183 (UMLS 2011AA Property-2)
C63321 (NCI Thesaurus Property-3)
C0948762 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Lab,Hematology,GranulocyteCount
Item
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
float
Lab,Hematology,GranDate
Item
Peripheral Granulocytes count, Date
date
Platelets
Item
Peripheral Platelet count, Done
boolean
C38148 (NCI Thesaurus ValueDomain)
C0005821 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Lab,Hematology,Platelets
Item
Peripheral Platelet count (mm3 Nadir)
float
Lab,Hematology,PlateletDate
Item
Peripheral Platelet count, Date
date
Hemoglobin
Item
Hemoglobin, Done
boolean
C38148 (NCI Thesaurus ValueDomain)
C0019046 (UMLS CUI-1)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Lab,Hematology,Hemoglobin
Item
Hemoglobin (G/DL Nadir)
float
Lab,Hematology,HGBDate
Item
Hemoglobin, Date
date
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
Item
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
text
CL.10
Code List
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
CL Item
Unrelated (Unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (Unlikely)
CL Item
Possibly (Possibly)
CL Item
Probably (Probably)
CL Item
Definitely (Definitely)
Item Group
Adverse Events - Section 3
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
CTCAdverseEventGrade
Item
CTC Adverse Event Grade
text
Item
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
text
CL.10
Code List
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
CL Item
Unrelated (Unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (Unlikely)
CL Item
Possibly (Possibly)
CL Item
Probably (Probably)
CL Item
Definitely (Definitely)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Footer Module
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
ParticipatingGroupProtocolNumber
Item
Participating Group Protocol Number
float
Trial subject ID Participating Group
Item
Participating Patient Study 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)
Item Group
Ccrr Module For Gog Common Toxicity Reporting Form
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