ID
804
Beskrivning
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
Länk
Nyckelord
Versioner (2)
- 2012-08-26 2012-08-26 -
- 2015-03-19 2015-03-19 - Martin Dugas
Uppladdad den
26 augusti 2012
DOI
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Licens
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.
Beskrivning
Unnamed2
Beskrivning
Patient'sName
Datatyp
text
Beskrivning
ParticipatingGroup
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beskrivning
PatientHospitalNumber
Datatyp
text
Beskrivning
ParticipatingGroupProtocolNo.
Datatyp
text
Beskrivning
MainMemberInstitution/Adjunct
Datatyp
text
Beskrivning
ParticipatingGroupPatientNo.
Datatyp
text
Beskrivning
Unnamed3
Beskrivning
Patient'sVitalStatus
Datatyp
text
Beskrivning
Causeofdeath
Datatyp
text
Beskrivning
DeathReason,Specify
Datatyp
text
Beskrivning
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Datatyp
text
Beskrivning
ProgressionAssessmentSource
Datatyp
text
Beskrivning
CancerFollow-upStatusDate
Datatyp
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beskrivning
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
ProgressionDate,FirstLocal-Regional
Datatyp
date
Beskrivning
ProgressionSite(s),FirstLocal-Regional
Datatyp
text
Beskrivning
Unnamed4
Beskrivning
Unnamed5
Beskrivning
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
ProgressionDate,FirstDistant
Datatyp
date
Beskrivning
ProgressionSite,FirstDistant
Datatyp
text
Beskrivning
ProgressionAssessmentSource
Datatyp
text
Beskrivning
Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
NewPrimaryCancerDate
Datatyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beskrivning
NewPrimarySite
Datatyp
text
Beskrivning
CurrentMenopausalStatus
Datatyp
text
Beskrivning
Resumptiondate
Datatyp
text
Beskrivning
Cessationdate
Datatyp
text
Beskrivning
Unnamed6
Beskrivning
Unnamed7
Beskrivning
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
IMTCode
Datatyp
text
Beskrivning
IMTCode
Datatyp
text
Beskrivning
CTCAdverseEventTerm
Datatyp
text
Beskrivning
CTCAdverseEventTerm
Datatyp
text
Beskrivning
Grade
Datatyp
double
Beskrivning
Grade
Datatyp
double
Beskrivning
DateofOnset
Datatyp
text
Beskrivning
DateofOnset
Datatyp
text
Beskrivning
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Non-ProtocolTherapy
Datatyp
text
Beskrivning
Non-ProtocolChemotherapyAdministeredSpecify
Datatyp
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
Beskrivning
Non-ProtocolHormoneTherapyAdministeredSpecify
Datatyp
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
Beskrivning
Non-protocolbiologicresponsemodifiertherapy,specify
Datatyp
text
Beskrivning
Non-ProtocolRadiationTherapyAdministeredSpecify
Datatyp
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
Beskrivning
Unnamed8
Beskrivning
Long-term Therapy
Beskrivning
PastTamoxifenInd
Datatyp
text
Beskrivning
CurrentTamoxifenInd
Datatyp
text
Beskrivning
Datetamoxifenstarted
Datatyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beskrivning
TamoxifenDiscontinuedDate
Datatyp
date
Beskrivning
Didthepatientreceiveanyaromataseinhibitors?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Whicharomataseinhibitor?
Datatyp
text
Beskrivning
Other,specify(aromataseinhibitor)
Datatyp
text
Beskrivning
Isthepatientstillreceivingaromataseinhibitor?
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
Datearomataseinhibitorstarted
Datatyp
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
Beskrivning
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Datatyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beskrivning
Comments
Beskrivning
Unnamed9
Beskrivning
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)