ID
804
Beschrijving
CALGB: 40101 FOLLOW-UP 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=A46CA742-FE60-27F9-E034-080020C9C0E0
Link
Trefwoorden
Versies (2)
- 26-08-12 26-08-12 -
- 19-03-15 19-03-15 - 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 Follow-Up - CALGB: 40101 FOLLOW-UP FORM - 2038050v3.0
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.
Beschrijving
Unnamed2
Beschrijving
Patient'sName
Datatype
text
Beschrijving
ParticipatingGroup
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschrijving
PatientHospitalNumber
Datatype
text
Beschrijving
ParticipatingGroupProtocolNo.
Datatype
text
Beschrijving
MainMemberInstitution/Adjunct
Datatype
text
Beschrijving
ParticipatingGroupPatientNo.
Datatype
text
Beschrijving
Unnamed3
Beschrijving
Patient'sVitalStatus
Datatype
text
Beschrijving
Causeofdeath
Datatype
text
Beschrijving
DeathReason,Specify
Datatype
text
Beschrijving
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Datatype
text
Beschrijving
ProgressionAssessmentSource
Datatype
text
Beschrijving
CancerFollow-upStatusDate
Datatype
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beschrijving
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
ProgressionDate,FirstLocal-Regional
Datatype
date
Beschrijving
ProgressionSite(s),FirstLocal-Regional
Datatype
text
Beschrijving
Unnamed4
Beschrijving
Unnamed5
Beschrijving
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
ProgressionDate,FirstDistant
Datatype
date
Beschrijving
ProgressionSite,FirstDistant
Datatype
text
Beschrijving
ProgressionAssessmentSource
Datatype
text
Beschrijving
Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
NewPrimaryCancerDate
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschrijving
NewPrimarySite
Datatype
text
Beschrijving
CurrentMenopausalStatus
Datatype
text
Beschrijving
Resumptiondate
Datatype
text
Beschrijving
Cessationdate
Datatype
text
Beschrijving
Unnamed6
Beschrijving
Unnamed7
Beschrijving
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
IMTCode
Datatype
text
Beschrijving
IMTCode
Datatype
text
Beschrijving
CTCAdverseEventTerm
Datatype
text
Beschrijving
CTCAdverseEventTerm
Datatype
text
Beschrijving
Grade
Datatype
double
Beschrijving
Grade
Datatype
double
Beschrijving
DateofOnset
Datatype
text
Beschrijving
DateofOnset
Datatype
text
Beschrijving
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Non-ProtocolTherapy
Datatype
text
Beschrijving
Non-ProtocolChemotherapyAdministeredSpecify
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15632
- UMLS 2011AA ObjectClass
- C0392920
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschrijving
Non-ProtocolHormoneTherapyAdministeredSpecify
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschrijving
Non-protocolbiologicresponsemodifiertherapy,specify
Datatype
text
Beschrijving
Non-ProtocolRadiationTherapyAdministeredSpecify
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschrijving
Unnamed8
Beschrijving
Long-term Therapy
Beschrijving
PastTamoxifenInd
Datatype
text
Beschrijving
CurrentTamoxifenInd
Datatype
text
Beschrijving
Datetamoxifenstarted
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschrijving
TamoxifenDiscontinuedDate
Datatype
date
Beschrijving
Didthepatientreceiveanyaromataseinhibitors?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Whicharomataseinhibitor?
Datatype
text
Beschrijving
Other,specify(aromataseinhibitor)
Datatype
text
Beschrijving
Isthepatientstillreceivingaromataseinhibitor?
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschrijving
Datearomataseinhibitorstarted
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C1740
- UMLS 2011AA ObjectClass
- C0593802
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschrijving
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschrijving
Comments
Beschrijving
Unnamed9
Beschrijving
Ccrr Module For Calgb: 40101 Follow-up Form
Similar models
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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0290882 (UMLS 2011AA)
C0246421 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C1740 (NCI Thesaurus ObjectClass)
C0593802 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)