ID
869
Description
NSABP PROTOCOL B-39: ADVERSE EVENT FORM FOR RADIATION THERAPY Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6F7DDC5-C879-6CDA-E034-0003BA3F9857
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Mots-clés
Versions (3)
- 26/08/2012 26/08/2012 -
- 08/01/2015 08/01/2015 - Martin Dugas
- 08/06/2015 08/06/2015 -
Téléchargé le
26 août 2012
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00103181 Toxicity - NSABP PROTOCOL B-39: ADVERSE EVENT FORM FOR RADIATION THERAPY - 2295182v3.0
This paper worksheet may be completed to facilitate the entry of the adverse event information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For Protocol B-39, Form AE collects only adverse events that are possibly, probably, or definitely related to whole breast irradiation (WBI) or partial breast irradiation (PBI), regardless of whether these adverse events are expected or unexpected. Do not report adverse events resulting from chemotherapy, hormonal therapy or any other systemic cancer therapy. Complete Form AE at the end of each Reporting Period, as defined below. The Reporting Period Start Date should not lapse or overlap with the Reporting Period End Date of the prior Form AE. If the patient has a breast cancer recurrence or second primary cancer, please use the date of the cancer event as the reporting period end date. No additional AE forms will be required for this patient. If patient did not start RT, do not submit Form AE. If patient started radiation therapy (RT), use Form AE to report adverse events that are POSSIBLY, PROBABLY, or DEFINITELY RELATED to radiation therapy.
Description
Unnamed2
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- UMLS 2011AA ValueDomain
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- NCI Thesaurus Property
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Description
AffiliatedInstitutionName
Type de données
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Description
ResponsiblePersonName
Type de données
text
Alias
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Description
DataAmendedInd-3
Type de données
text
Alias
- NCI Thesaurus ValueDomain
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Description
Unnamed3
Description
ReportingEvaluationPeriodType
Type de données
text
Alias
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Description
Unnamed4
Description
TreatmentReportingPeriodBeginDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
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- UMLS 2011AA Property
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- NCI Thesaurus ValueDomain
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- UMLS 2011AA ValueDomain
- C0011008
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- UMLS 2011AA ValueDomain
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Description
CommonTerminologyCriteriaforAdverseEventsVersion4.0LowLevelTermName
Type de données
text
Alias
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Description
TreatmentReportingPeriodEndDate
Type de données
date
Alias
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Description
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Alias
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- NCI Thesaurus ValueDomain
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Description
PatientHospitalizationInd-2
Type de données
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Alias
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Description
Ii. Infections
Description
CommonTerminologyCriteriaforAdverseEventsVersion4.0LowLevelTermName
Type de données
text
Alias
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- UMLS 2011AA ValueDomain
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- C1705313
- NCI Thesaurus ValueDomain
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- UMLS 2011AA ValueDomain
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Description
AdverseEventSeverityGrade
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus Property
- C48309
- UMLS 2011AA Property
- C0441800
- NCI Thesaurus Property
- C49705
- UMLS 2011AA Property
- C1710065
- NCI Thesaurus Property
- C25676
- UMLS 2011AA Property
- C0439793
- NCI Thesaurus ValueDomain
- C41331
- UMLS 2011AA ValueDomain
- C0877248
- NCI Thesaurus ValueDomain
- C48309
- UMLS 2011AA ValueDomain
- C0441800
- NCI Thesaurus ValueDomain
- C25676
- UMLS 2011AA ValueDomain
- C0439793
Description
Comments
Similar models
This paper worksheet may be completed to facilitate the entry of the adverse event information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For Protocol B-39, Form AE collects only adverse events that are possibly, probably, or definitely related to whole breast irradiation (WBI) or partial breast irradiation (PBI), regardless of whether these adverse events are expected or unexpected. Do not report adverse events resulting from chemotherapy, hormonal therapy or any other systemic cancer therapy. Complete Form AE at the end of each Reporting Period, as defined below. The Reporting Period Start Date should not lapse or overlap with the Reporting Period End Date of the prior Form AE. If the patient has a breast cancer recurrence or second primary cancer, please use the date of the cancer event as the reporting period end date. No additional AE forms will be required for this patient. If patient did not start RT, do not submit Form AE. If patient started radiation therapy (RT), use Form AE to report adverse events that are POSSIBLY, PROBABLY, or DEFINITELY RELATED to radiation therapy.
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15818 (NCI Thesaurus Property)
C1513905 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0018704 (UMLS 2011AA ObjectClass)
C25413 (NCI Thesaurus ObjectClass)
C1510826 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
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C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus ObjectClass)
C0700287 (UMLS 2011AA ObjectClass)
C0205448 (UMLS 2011AA)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C0877248 (UMLS 2011AA ObjectClass)
C49704 (NCI Thesaurus Property)
C1516728 (UMLS 2011AA Property)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
C45255 (NCI Thesaurus ValueDomain)
C1708523 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ValueDomain)
C1516728 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C45559 (NCI Thesaurus ValueDomain)
C1705313 (UMLS 2011AA ValueDomain)
C25714 (NCI Thesaurus ValueDomain)
C0333052 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C0877248 (UMLS 2011AA ObjectClass)
C48309 (NCI Thesaurus Property)
C0441800 (UMLS 2011AA Property)
C49705 (NCI Thesaurus Property)
C1710065 (UMLS 2011AA Property)
C25676 (NCI Thesaurus Property)
C0439793 (UMLS 2011AA Property)
C41331 (NCI Thesaurus ValueDomain)
C0877248 (UMLS 2011AA ValueDomain)
C48309 (NCI Thesaurus ValueDomain)
C0441800 (UMLS 2011AA ValueDomain)
C25676 (NCI Thesaurus ValueDomain)
C0439793 (UMLS 2011AA ValueDomain)
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C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25179 (NCI Thesaurus Property)
C0019993 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0877248 (UMLS 2011AA ObjectClass)
C49704 (NCI Thesaurus Property)
C1516728 (UMLS 2011AA Property)
C45559 (NCI Thesaurus Property)
C1705313 (UMLS 2011AA Property)
C45255 (NCI Thesaurus ValueDomain)
C1708523 (UMLS 2011AA ValueDomain)
C49704 (NCI Thesaurus ValueDomain)
C1516728 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C45559 (NCI Thesaurus ValueDomain)
C1705313 (UMLS 2011AA ValueDomain)
C25714 (NCI Thesaurus ValueDomain)
C0333052 (UMLS 2011AA ValueDomain)
C0877248 (UMLS 2011AA ObjectClass)
C48309 (NCI Thesaurus Property)
C0441800 (UMLS 2011AA Property)
C49705 (NCI Thesaurus Property)
C1710065 (UMLS 2011AA Property)
C25676 (NCI Thesaurus Property)
C0439793 (UMLS 2011AA Property)
C41331 (NCI Thesaurus ValueDomain)
C0877248 (UMLS 2011AA ValueDomain)
C48309 (NCI Thesaurus ValueDomain)
C0441800 (UMLS 2011AA ValueDomain)
C25676 (NCI Thesaurus ValueDomain)
C0439793 (UMLS 2011AA ValueDomain)
C1513302 (UMLS 2011AA)
C1513374 (UMLS 2011AA)
C2919019 (UMLS 2011AA)
C1517874 (UMLS 2011AA)
C1705232 (UMLS 2011AA)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)