ID

8328

Description

RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form Higher-Dose Radiation Therapy or Standard Radiation Therapy in Treating Patients With Early-Stage Breast Cancer That Was Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E3CC0E2-B278-1265-E040-BB89AD430CE0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E3CC0E2-B278-1265-E040-BB89AD430CE0

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT01349322 Quality of Life - RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form - 3202750v1.0

English

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms  
  1. StudyEvent: RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

Protocol ID RTOG

Data type

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

Data type

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

Data type

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

Data type

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

Data type

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

Data type

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
Are data amended
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Unamed Module 2
Description

Unamed Module 2

Will cosmesis photographs be submitted for this time period?
Description

PhotographBreastReconstructionSubmissionInd-3

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C25694
UMLS 2011AA Property-2
C1515022
NCI Thesaurus Property-3
C25351
UMLS 2011AA Property-3
C0524865
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Time point
Description

AssessmentPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Date photographs taken
Description

PhotographBreastReconstructionTakenDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C25351
UMLS 2011AA Property-2
C0524865
NCI Thesaurus Property-3
C25701
UMLS 2011AA Property-3
C1883727
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Date photographs submitted via RTOG website
Description

PhotographBreastReconstructionSubmissionDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C12971
UMLS 2011AA Property
C0006141
NCI Thesaurus Property-2
C25694
UMLS 2011AA Property-2
C1515022
NCI Thesaurus Property-3
C25351
UMLS 2011AA Property-3
C0524865
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Reason photographs not submitted
Description

PhotographBreastReconstructionNoSubmissionReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus Property-2
C12971
UMLS 2011AA Property-2
C0006141
NCI Thesaurus Property-3
C25694
UMLS 2011AA Property-3
C1515022
NCI Thesaurus Property-4
C25351
UMLS 2011AA Property-4
C0524865
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Description

PhotographBreastReconstructionNoSubmissionSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C86035
UMLS 2011AA ObjectClass
C0441468
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus Property-2
C12971
UMLS 2011AA Property-2
C0006141
NCI Thesaurus Property-3
C25694
UMLS 2011AA Property-3
C1515022
NCI Thesaurus Property-4
C25351
UMLS 2011AA Property-4
C0524865
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C15368
Signature of Person Completing This Form
Description

Responsible Person Signature

Data type

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
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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Similar models

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms
  1. StudyEvent: RTOG-1005 T7: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Photograph Submission Notification Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 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
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Unamed Module 2
PhotographBreastReconstructionSubmissionInd-3
Item
Will cosmesis photographs be submitted for this time period?
boolean
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property-2)
C1515022 (UMLS 2011AA Property-2)
C25351 (NCI Thesaurus Property-3)
C0524865 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.3
Code List
Time point
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
1 Year Post Rt Completion (1 year post RT Completion)
CL Item
3 Years Post Rt Completion (3 years post RT Completion)
PhotographBreastReconstructionTakenDate
Item
Date photographs taken
date
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25351 (NCI Thesaurus Property-2)
C0524865 (UMLS 2011AA Property-2)
C25701 (NCI Thesaurus Property-3)
C1883727 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhotographBreastReconstructionSubmissionDate
Item
Date photographs submitted via RTOG website
date
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus Property)
C0006141 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property-2)
C1515022 (UMLS 2011AA Property-2)
C25351 (NCI Thesaurus Property-3)
C0524865 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Reason photographs not submitted
text
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C12971 (NCI Thesaurus Property-2)
C0006141 (UMLS 2011AA Property-2)
C25694 (NCI Thesaurus Property-3)
C1515022 (UMLS 2011AA Property-3)
C25351 (NCI Thesaurus Property-4)
C0524865 (UMLS 2011AA Property-4)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.4
Code List
Reason photographs not submitted
CL Item
Other (Other)
CL Item
Patient Death (Patient death)
CL Item
Patient Refused (Patient refused)
CL Item
Patient Too Ill (Patient too ill)
CL Item
Patient Withdrew Consent (Patient withdrew consent)
CL Item
Photographs Not Taken (institution Error) (Photographs not taken (Institution Error))
CL Item
Recurrence / Second Primary (Recurrence / Second Primary)
PhotographBreastReconstructionNoSubmissionSpecify
Item
Other, specify
text
C86035 (NCI Thesaurus ObjectClass)
C0441468 (UMLS 2011AA ObjectClass)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C12971 (NCI Thesaurus Property-2)
C0006141 (UMLS 2011AA Property-2)
C25694 (NCI Thesaurus Property-3)
C1515022 (UMLS 2011AA Property-3)
C25351 (NCI Thesaurus Property-4)
C0524865 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ValueDomain-2)
Responsible Person Signature
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Date Form Completed
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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