0 Avaliações
ID

8229

Descrição

T1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Radiotherapy Form Radiation Therapy in Treating Patients With Stage II Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11E22AA5-BFC0-32E2-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11E22AA5-BFC0-32E2-E044-0003BA3F9857

Palavras-chave

Versões (2)
  1. 2012-09-20 2012-09-20 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Transferido a

9 januari 2015

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

  • Os mais recentes
  • Os mais antigos
  • Preferidos
  • Os mais recentes
    • Os mais recentes
    • Os mais antigos
    • Preferidos

    Sem comentários

    Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

    Prostate Cancer NCT00033631 Treatment - T1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Radiotherapy Form - 2478411v1.0

    Inglês

    Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. Dates are recorded mm-dd-yyyy unless otherwise specified. A copy much be submitted to RTOG HQ and the ITC.

    1 Formulários  
    Module 1
    Descrição

    Module 1

    RTOG Study No.
    Descrição

    Protocol ID RTOG

    Tipo de dados

    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 #
    Descrição

    Case#

    Tipo de dados

    text

    Institution
    Descrição

    Institution Name

    Tipo de dados

    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.
    Descrição

    Institution Number

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Participant's Initials
    Descrição

    Patient Initials

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Participant's I.D. No.
    Descrição

    Patient Study ID

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    If this is a revised or corrected form, indicate by checking box.
    Descrição

    CaseReportFormModifiedInd-2

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C25573
    RADIATION THERAPY START DATE
    Descrição

    Radiation Therapy Start Date

    Tipo de dados

    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
    Descrição

    Radiation Therapy End Date

    Tipo de dados

    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
    Descrição

    RadiationTherapyTotalDayCount

    Tipo de dados

    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
    TOTAL FRACTIONS
    Descrição

    Total Number of Fractions

    Tipo de dados

    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
    TOTAL DOSE (Gy)
    Descrição

    Radiation Therapy Total Dose

    Tipo de dados

    float

    Alias
    NCI Thesaurus ValueDomain
    C25304
    UMLS CUI-1
    C2169193
    NCI Thesaurus ObjectClass
    C15313
    NCI Thesaurus ValueDomain-2
    C25488
    NCI Thesaurus Property
    C25382
    Performance Status (Zubrod 0-4)
    Descrição

    PerformanceStatus

    Tipo de dados

    text

    WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY?
    Descrição

    Unscheduled Interruptions in Radiation Therapy

    Tipo de dados

    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
    Descrição

    Radiation Therapy Interruption Reason

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-1
    C1522449
    NCI Thesaurus Property
    C25594
    UMLS CUI-2
    C3538832
    NCI Thesaurus Property-2
    C25211
    NCI Thesaurus Property-3
    C25542
    NCI Thesaurus ValueDomain
    C25685
    REASON RADIATION THERAPY TREATMENT ENDED
    Descrição

    TreatmentDiscontinuedType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25484
    UMLS 2011AA Property
    C1444662
    Alternative therapy, specify
    Descrição

    Alternative therapy, specify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0949216
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C25415
    NCI Thesaurus Property
    C25382
    Other complicating disease, specify
    Descrição

    Off-TreatmentConditionSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus Property
    C25457
    UMLS 2011AA Property
    C0348080
    Other, specify
    Descrição

    Off-TreatmentOtherReasonSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus Property-2
    C25365
    UMLS 2011AA Property-2
    C0678257
    Type of Radiation Therapy Administered (Which modality was used to treat this patient)
    Descrição

    Radiation Therapy Type

    Tipo de dados

    text

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

    Research Comments

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Signature of person completing form
    Descrição

    Responsible Person Signature

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25190
    NCI Thesaurus ObjectClass-2
    C25657
    NCI Thesaurus Property
    C25678
    Date form completed, original
    Descrição

    Form Completion Date

    Tipo de dados

    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
    Voltar ao início da página

    Similar models

    Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. Dates are recorded mm-dd-yyyy unless otherwise specified. A copy much be submitted to RTOG HQ and the ITC.

    1 Formulários
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    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)
    Case#
    Item
    Case #
    text
    Institution Name
    Item
    Institution
    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
    Participant's Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Patient Study ID
    Item
    Participant's I.D. No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    CaseReportFormModifiedInd-2
    Item
    If this is a revised or corrected form, indicate by checking box.
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25573 (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
    TOTAL FRACTIONS
    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
    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
    Performance Status (Zubrod 0-4)
    text
    CL.1
    Code List
    Performance Status (Zubrod 0-4)
    CL Item
    0 (Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90 - 100))
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
    CL Item
    2 (Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50 - 60))
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (K 30 - 40))
    CL Item
    4 (Completely disabled (K 10 - 20))
    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)
    Radiation Therapy Interruption Reason
    Item
    Specify RT interruption reason
    text
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS CUI-1)
    C25594 (NCI Thesaurus Property)
    C3538832 (UMLS CUI-2)
    C25211 (NCI Thesaurus Property-2)
    C25542 (NCI Thesaurus Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    Item
    REASON RADIATION THERAPY TREATMENT ENDED
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25484 (NCI Thesaurus Property)
    C1444662 (UMLS 2011AA Property)
    CL.3
    Code List
    REASON RADIATION THERAPY TREATMENT ENDED
    CL Item
    Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
    CL Item
    Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
    CL Item
    Toxicity/side Effects/complications (Toxicity/side effects/complications)
    CL Item
    Death On Study (Death on study)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
    CL Item
    Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
    CL Item
    Alternative Therapy (Alternative therapy)
    CL Item
    Other Complicating Disease (Other complicating disease)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Alternative therapy, specify
    Item
    Alternative therapy, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0949216 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25415 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    Off-TreatmentConditionSpecify
    Item
    Other complicating disease, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25457 (NCI Thesaurus Property)
    C0348080 (UMLS 2011AA Property)
    Off-TreatmentOtherReasonSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    Item
    Type of Radiation Therapy Administered (Which modality was used to treat this patient)
    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 (Which modality was used to treat this patient)
    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)
    Responsible Person Signature
    Item
    Signature of person completing form
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25190 (NCI Thesaurus ObjectClass)
    C25657 (NCI Thesaurus ObjectClass-2)
    C25678 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Date form completed, original
    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)
    Voltar ao início da página 

    Ajuda

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial