ID

8328

Beskrivning

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

Länk

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

Nyckelord

Versioner (2)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 09/01/2015 09/01/2015 - Martin Dugas
Uppladdad den

9 janvier 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

  • Senaste
  • Äldsta
  • Önskad
  • Senaste
    • Senaste
    • Äldsta
    • Önskad

    Inga kommentarer

    Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

    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

    Engelsk

    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 Formulär  
    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
    Beskrivning

    Unnamed Module 1

    RTOG Study No.
    Beskrivning

    Protocol ID RTOG

    Datatyp

    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 #
    Beskrivning

    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

    Datatyp

    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
    Beskrivning

    Institution Name

    Datatyp

    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.
    Beskrivning

    Institution Number

    Datatyp

    text

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

    Patient Initials

    Datatyp

    text

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

    Trial subject ID RTOG

    Datatyp

    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
    Beskrivning

    Data amended

    Datatyp

    boolean

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

    Unamed Module 2

    Will cosmesis photographs be submitted for this time period?
    Beskrivning

    PhotographBreastReconstructionSubmissionInd-3

    Datatyp

    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
    Beskrivning

    AssessmentPeriodType

    Datatyp

    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
    Beskrivning

    PhotographBreastReconstructionTakenDate

    Datatyp

    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
    Beskrivning

    PhotographBreastReconstructionSubmissionDate

    Datatyp

    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
    Beskrivning

    PhotographBreastReconstructionNoSubmissionReason

    Datatyp

    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
    Beskrivning

    PhotographBreastReconstructionNoSubmissionSpecify

    Datatyp

    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
    Beskrivning

    Responsible Person Signature

    Datatyp

    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
    Beskrivning

    Date Form Completed

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1115437
    NCI Thesaurus ObjectClass
    C40988
    NCI Thesaurus Property
    C25250
    NCI Thesaurus ValueDomain-2
    C25367
    Tillbaka till toppen

    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 Formulär
    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
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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)
    Tillbaka till toppen 

    Hjälp

    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