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8209

Description

RTOG 0848: Phase III Pancreas-Resected + Adjuvant Treatment Radiotherapy Form (T1) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=69073BF6-D406-B01F-E040-BB89AD4319AC

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=69073BF6-D406-B01F-E040-BB89AD4319AC

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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    Pancreatic Cancer NCT01013649 Treatment - RTOG 0848: Phase III Pancreas-Resected + Adjuvant Treatment Radiotherapy Form (T1) - 2866961v1.0

    Anglais

    Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mm-dd-yyy unless specifieid otherwise.

    1 Formulaires  
    1. StudyEvent: RTOG 0848: Phase III Pancreas-Resected + Adjuvant Treatment Radiotherapy Form (T1)
      1. Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mm-dd-yyy unless specifieid otherwise.
    Module 1
    Description

    Module 1

    RTOG Study No.
    Description

    Protocol ID RTOG

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1514695
    NCI Thesaurus Property
    C19778
    NCI Thesaurus Property-2
    C25364
    Case #
    Description

    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C19778
    UMLS 2011AA ObjectClass-2
    C1514695
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C49152
    UMLS 2011AA Property-2
    C1706256
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Institution Name
    Description

    Institution Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Institution No.
    Description

    Institution Number

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Patient Initials
    Description

    Patient Initials

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    RTOG Patient ID
    Description

    Trial subject ID RTOG

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1514695
    NCI Thesaurus Property
    C19778
    NCI Thesaurus Property-2
    C25364
    Amended Data
    Description

    Data amended

    Type de données

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Radiation Therapy Start Date
    Description

    Radiation Therapy Start Date

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-1
    C1522449
    NCI Thesaurus Property
    C25431
    UMLS CUI-2
    C0808070
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Radiation Therapy End Date
    Description

    Radiation Therapy End Date

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C0806020
    NCI Thesaurus Property
    C25275
    NCI Thesaurus Property-2
    C25496
    Elapsed days
    Description

    RadiationTherapyTotalDayCount

    Type de données

    float

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C25304
    UMLS 2011AA Property
    C0439810
    NCI Thesaurus Property-2
    C25301
    UMLS 2011AA Property-2
    C0439228
    NCI Thesaurus ValueDomain
    C25301
    UMLS 2011AA ValueDomain
    C0439228
    NCI Thesaurus ValueDomain-2
    C25463
    UMLS 2011AA ValueDomain-2
    C0750480
    RT Total Fraction Count
    Description

    Total Number of Fractions

    Type de données

    float

    Alias
    NCI Thesaurus Property
    C25304
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C1264633
    NCI Thesaurus ValueDomain
    C25463
    UMLS CUI-3
    C0750480
    NCI Thesaurus Property-2
    C25514
    RT Total Dose (Gy)
    Description

    Radiation Therapy Total Dose

    Type de données

    float

    Alias
    NCI Thesaurus ValueDomain
    C25304
    UMLS CUI-1
    C2169193
    NCI Thesaurus ObjectClass
    C15313
    NCI Thesaurus ValueDomain-2
    C25488
    NCI Thesaurus Property
    C25382
    Were there any unscheduled interruptions in radiation therapy?
    Description

    Unscheduled Interruptions in Radiation Therapy

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C1512900
    NCI Thesaurus Property
    C25542
    Specify RT interruption reason
    Description

    RadiationTherapyUnscheduledInterruptionSpecify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus Property-2
    C25211
    UMLS 2011AA Property-2
    C0086960
    NCI Thesaurus Property-3
    C25542
    UMLS 2011AA Property-3
    C1512900
    Reason Treatment Ended
    Description

    Off Treatment Reason

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C1518544
    NCI Thesaurus ObjectClass
    C25601
    UMLS CUI-2
    C0566251
    NCI Thesaurus Property
    C25365
    Alternative Therapy
    Description

    Off-treatmentAlternativeReasonSpecify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus Property
    C25415
    UMLS 2011AA Property
    C1523987
    NCI Thesaurus Property-2
    C25365
    UMLS 2011AA Property-2
    C0678257
    Other specify
    Description

    Off Treatment Reason, specify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C1518544
    NCI Thesaurus ObjectClass
    C25601
    UMLS CUI-2
    C0566251
    NCI Thesaurus Property
    C25365
    UMLS CUI-3
    C1521902
    Type of Radiation Therapy Administered
    Description

    Radiation Therapy Type

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C0683312
    NCI Thesaurus Property
    C25382
    Comments
    Description

    Research Comments

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Person Completing Form
    Description

    Person Completing Form

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Date form originally completed
    Description

    Form Completion Date

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C1549507
    NCI Thesaurus Property
    C25250
    NCI Thesaurus Property-2
    C25604
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Retour au début de la page

    Similar models

    Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mm-dd-yyy unless specifieid otherwise.

    1 Formulaires
    1. StudyEvent: RTOG 0848: Phase III Pancreas-Resected + Adjuvant Treatment Radiotherapy Form (T1)
      1. Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mm-dd-yyy unless specifieid otherwise.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Module 1
    Protocol ID RTOG
    Item
    RTOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS CUI-2)
    C19778 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
    Item
    Case #
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C19778 (NCI Thesaurus ObjectClass-2)
    C1514695 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C49152 (NCI Thesaurus Property-2)
    C1706256 (UMLS 2011AA Property-2)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    Institution Name
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Trial subject ID RTOG
    Item
    RTOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS CUI-2)
    C19778 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Data amended
    Item
    Amended Data
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Radiation Therapy Start Date
    Item
    Radiation Therapy Start Date
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS CUI-1)
    C25431 (NCI Thesaurus Property)
    C0808070 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Radiation Therapy End Date
    Item
    Radiation Therapy End Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0806020 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    RadiationTherapyTotalDayCount
    Item
    Elapsed days
    float
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C25304 (NCI Thesaurus Property)
    C0439810 (UMLS 2011AA Property)
    C25301 (NCI Thesaurus Property-2)
    C0439228 (UMLS 2011AA Property-2)
    C25301 (NCI Thesaurus ValueDomain)
    C0439228 (UMLS 2011AA ValueDomain)
    C25463 (NCI Thesaurus ValueDomain-2)
    C0750480 (UMLS 2011AA ValueDomain-2)
    Total Number of Fractions
    Item
    RT Total Fraction Count
    float
    C25304 (NCI Thesaurus Property)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C1264633 (UMLS CUI-2)
    C25463 (NCI Thesaurus ValueDomain)
    C0750480 (UMLS CUI-3)
    C25514 (NCI Thesaurus Property-2)
    Radiation Therapy Total Dose
    Item
    RT Total Dose (Gy)
    float
    C25304 (NCI Thesaurus ValueDomain)
    C2169193 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C25488 (NCI Thesaurus ValueDomain-2)
    C25382 (NCI Thesaurus Property)
    Item
    Were there any unscheduled interruptions in radiation therapy?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C1512900 (UMLS CUI-2)
    C25542 (NCI Thesaurus Property)
    CL.2
    Code List
    Were there any unscheduled interruptions in radiation therapy?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Due To Toxicity (Yes, due to toxicity)
    CL Item
    Yes, Due To Other Reason (Yes, due to other reason)
    RadiationTherapyUnscheduledInterruptionSpecify
    Item
    Specify RT interruption reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C25211 (NCI Thesaurus Property-2)
    C0086960 (UMLS 2011AA Property-2)
    C25542 (NCI Thesaurus Property-3)
    C1512900 (UMLS 2011AA Property-3)
    Item
    Reason Treatment Ended
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    CL.3
    Code List
    Reason Treatment Ended
    CL Item
    Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
    CL Item
    Alternative Therapy (Alternative therapy)
    CL Item
    Death On Study (Death on study)
    CL Item
    Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)
    CL Item
    Patient Withdrawal Or Refusal Before Beginning Protocol Therapy (Patient withdrawal/refusal prior to beginning protocol therapy)
    CL Item
    Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
    Off-treatmentAlternativeReasonSpecify
    Item
    Alternative Therapy
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25415 (NCI Thesaurus Property)
    C1523987 (UMLS 2011AA Property)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    Off Treatment Reason, specify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    C1521902 (UMLS CUI-3)
    Item
    Type of Radiation Therapy Administered
    text
    C25284 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0683312 (UMLS CUI-2)
    C25382 (NCI Thesaurus Property)
    CL.4
    Code List
    Type of Radiation Therapy Administered
    CL Item
    3d Conformal (3D conformal)
    CL Item
    Imrt (IMRT)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Person Completing Form
    Item
    Person Completing Form
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Date form originally completed
    date
    C19464 (NCI Thesaurus ObjectClass)
    C1549507 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C25604 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Retour au début de la page 

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