0 Ratings
ID

8723

Description

Z1041: Extended Follow-up Form Combination Chemotherapy and Paclitaxel Plus Trastuzumab in Treating Women With Palpable Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211CBE88-1531-5AB5-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211CBE88-1531-5AB5-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

  • Newest
  • Oldest
  • Popular
  • Newest
    • Newest
    • Oldest
    • Popular

    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    Breast Cancer NCT00513292 Follow-Up - Z1041: Extended Follow-up Form - 2533635v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Z1041: Extended Follow-up Form
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Visit
    Description

    AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C19712
    UMLS 2011AA ObjectClass
    C1515944
    NCI Thesaurus ObjectClass-2
    C25716
    UMLS 2011AA ObjectClass-2
    C0545082
    Date
    Description

    PatientNotScheduleVisitDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus Property-2
    C25211
    UMLS 2011AA Property-2
    C0086960
    NCI Thesaurus Property-3
    C25716
    UMLS 2011AA Property-3
    C0545082
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Patient ID (Patient ID issued during registration or previously issued Patient ID.)
    Description

    Patient Study ID

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Patient Initials (F M L)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    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
    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
    Header
    Description

    Header

    Vital status
    Description

    Patient Status

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C3846084
    NCI Thesaurus ValueDomain
    C18003
    NCI Thesaurus ValueDomain-2
    C25688
    NCI Thesaurus Property
    C25717
    Date of Last Contact or Death (Year Month e.g., JAN Day)
    Description

    Date last contact

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C0805839
    NCI Thesaurus Property
    C25461
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Primary Cause of Death (If deceased,)
    Description

    Primary Cause of Death

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C28554
    NCI Thesaurus ValueDomain-2
    C25251
    Describe cause of death
    Description

    Cause of Death, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0007465
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1521902
    NCI Thesaurus Property
    C28554
    Was imaging done to assess for recurrence
    Description

    DiagnosticImagingRecurrentDiseasePerformedInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16502
    UMLS 2011AA ObjectClass
    C0011923
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus Property-2
    C38155
    UMLS 2011AA Property-2
    C0277556
    Image date
    Description

    DiagnosticImagingProcedureDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C16502
    UMLS 2011AA ObjectClass
    C0011923
    NCI Thesaurus Property
    C25218
    UMLS 2011AA Property
    C1948041
    Notice Of First Recurrence/progression
    Description

    Notice Of First Recurrence/progression

    Has the patient developed a first progression (or relapse) that has not been previously reported?
    Description

    DiseaseProgressionInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C25331
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    First recurrence/progression
    Description

    BreastCancerFirstProgressionType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25331
    NCI Thesaurus ObjectClass
    C4872
    UMLS 2011AA ObjectClass
    C0678222
    NCI Thesaurus Property-2
    C25509
    UMLS 2011AA Property
    C1279901
    Date of first recurrence/progression
    Description

    RecurrentDiseaseCancerProgressionFirstDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C38155
    UMLS 2011AA ObjectClass
    C0277556
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Thesaurus Property-3
    C19987
    UMLS 2011AA Property-3
    C0242656
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    Site of first recurrence/progression
    Description

    BreastCancerFirstProgressionSite

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus Property
    C25331
    NCI Thesaurus ObjectClass
    C4872
    UMLS 2011AA ObjectClass
    C0678222
    NCI Thesaurus Property-2
    C25509
    UMLS 2011AA Property
    C1279901
    Other, specify
    Description

    Progression Site, specify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0242656
    NCI Thesaurus Property
    C25341
    UMLS CUI-2
    C1515974
    NCI Thesaurus ObjectClass
    C25331
    Notice Of New Primary
    Description

    Notice Of New Primary

    Has a new primary cancer or MDS been diagnosed that has not been previously reported?
    Description

    New primary cancer

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS CUI-1
    C0751623
    NCI Thesaurus ObjectClass
    C25586
    NCI Thesaurus ObjectClass-2
    C9305
    NCI Thesaurus Property
    C15220
    Date of diagnosis
    Description

    NewCancerDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C25586
    UMLS 2011AA ObjectClass
    C0205314
    NCI Thesaurus ObjectClass-2
    C9305
    UMLS 2011AA ObjectClass-2
    C0006826
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    New Primary, Histologic type
    Description

    PrimaryTumorNewHistologicCategory

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass-2
    C25251
    UMLS 2011AA ObjectClass-2
    C0205225
    NCI Thesaurus Property
    C25586
    UMLS 2011AA Property
    C0205314
    NCI Thesaurus Property-2
    C25161
    UMLS 2011AA Property-2
    C0008902
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ValueDomain-2
    C25526
    UMLS 2011AA ValueDomain-2
    C0205462
    Footer Module
    Description

    Footer Module

    Completed by
    Description

    Person Completing Form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    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
    Back to the top of the page

    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: Z1041: Extended Follow-up Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header Module
    Item
    Visit
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C19712 (NCI Thesaurus ObjectClass)
    C1515944 (UMLS 2011AA ObjectClass)
    C25716 (NCI Thesaurus ObjectClass-2)
    C0545082 (UMLS 2011AA ObjectClass-2)
    CL.1
    Code List
    Visit
    CL Item
    30 Days Post Surgery (30 Days post surgery)
    CL Item
    Mo3fu (Mo3FU)
    CL Item
    Mo6fu (Mo6FU)
    CL Item
    Mo9fu (Mo9FU)
    CL Item
    Mo12fu (Mo12FU)
    CL Item
    Mo15fu (Mo15FU)
    CL Item
    Mo18fu (Mo18FU)
    CL Item
    Mo24fu (Mo24FU)
    CL Item
    Mo30fu (Mo30FU)
    CL Item
    Mo36fu (Mo36FU)
    CL Item
    Mo42fu (Mo42FU)
    CL Item
    Mo48fu (Mo48FU)
    CL Item
    Mo54fu (Mo54FU)
    CL Item
    Unscheduled (Unscheduled)
    PatientNotScheduleVisitDate
    Item
    Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C25211 (NCI Thesaurus Property-2)
    C0086960 (UMLS 2011AA Property-2)
    C25716 (NCI Thesaurus Property-3)
    C0545082 (UMLS 2011AA Property-3)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Patient Study ID
    Item
    Patient ID (Patient ID issued during registration or previously issued Patient ID.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Patient Initials
    Item
    Patient Initials (F M L)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (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)
    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)
    Item Group
    Header
    Item
    Vital status
    text
    C16960 (NCI Thesaurus ObjectClass)
    C3846084 (UMLS CUI-1)
    C18003 (NCI Thesaurus ValueDomain)
    C25688 (NCI Thesaurus ValueDomain-2)
    C25717 (NCI Thesaurus Property)
    CL.2
    Code List
    Vital status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    Date last contact
    Item
    Date of Last Contact or Death (Year Month e.g., JAN Day)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0805839 (UMLS CUI-1)
    C25461 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    Primary Cause of Death (If deceased,)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C28554 (NCI Thesaurus Property)
    C25251 (NCI Thesaurus ValueDomain-2)
    CL.3
    Code List
    Primary Cause of Death (If deceased,)
    CL Item
    Due To This Disease (Due to this disease)
    CL Item
    Due To Protocol Treatment (Due to protocol treatment)
    CL Item
    Due To Cardiovascular Disease (Due to cardiovascular disease)
    CL Item
    Due To Other Cause (Due to other cause)
    Cause of Death, specify
    Item
    Describe cause of death
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0007465 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-2)
    C28554 (NCI Thesaurus Property)
    DiagnosticImagingRecurrentDiseasePerformedInd-3
    Item
    Was imaging done to assess for recurrence
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16502 (NCI Thesaurus ObjectClass)
    C0011923 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C38155 (NCI Thesaurus Property-2)
    C0277556 (UMLS 2011AA Property-2)
    DiagnosticImagingProcedureDate
    Item
    Image date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    C16502 (NCI Thesaurus ObjectClass)
    C0011923 (UMLS 2011AA ObjectClass)
    C25218 (NCI Thesaurus Property)
    C1948041 (UMLS 2011AA Property)
    Item Group
    Notice Of First Recurrence/progression
    DiseaseProgressionInd-3
    Item
    Has the patient developed a first progression (or relapse) that has not been previously reported?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25331 (NCI Thesaurus Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    Item
    First recurrence/progression
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25331 (NCI Thesaurus Property)
    C4872 (NCI Thesaurus ObjectClass)
    C0678222 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property-2)
    C1279901 (UMLS 2011AA Property)
    CL.6
    Code List
    First recurrence/progression
    CL Item
    Local (Local)
    CL Item
    Regional (Regional)
    C25643 (NCI Thesaurus)
    C0205147 (UMLS 2011AA)
    CL Item
    Distant (Distant)
    RecurrentDiseaseCancerProgressionFirstDiagnosisDate
    Item
    Date of first recurrence/progression
    date
    C38155 (NCI Thesaurus ObjectClass)
    C0277556 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C19987 (NCI Thesaurus Property-3)
    C0242656 (UMLS 2011AA Property-3)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    Site of first recurrence/progression
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C25331 (NCI Thesaurus Property)
    C4872 (NCI Thesaurus ObjectClass)
    C0678222 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property-2)
    C1279901 (UMLS 2011AA Property)
    CL.7
    Code List
    Site of first recurrence/progression
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Ln (LN)
    CL Item
    Lung/pleura (Lung/pleura)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Progression Site, specify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0242656 (UMLS CUI-1)
    C25341 (NCI Thesaurus Property)
    C1515974 (UMLS CUI-2)
    C25331 (NCI Thesaurus ObjectClass)
    Item Group
    Notice Of New Primary
    New primary cancer
    Item
    Has a new primary cancer or MDS been diagnosed that has not been previously reported?
    boolean
    C25180 (NCI Thesaurus ValueDomain)
    C0751623 (UMLS CUI-1)
    C25586 (NCI Thesaurus ObjectClass)
    C9305 (NCI Thesaurus ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    NewCancerDiagnosisDate
    Item
    Date of diagnosis
    date
    C25586 (NCI Thesaurus ObjectClass)
    C0205314 (UMLS 2011AA ObjectClass)
    C9305 (NCI Thesaurus ObjectClass-2)
    C0006826 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    PrimaryTumorNewHistologicCategory
    Item
    New Primary, Histologic type
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25251 (NCI Thesaurus ObjectClass-2)
    C0205225 (UMLS 2011AA ObjectClass-2)
    C25586 (NCI Thesaurus Property)
    C0205314 (UMLS 2011AA Property)
    C25161 (NCI Thesaurus Property-2)
    C0008902 (UMLS 2011AA Property-2)
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C25526 (NCI Thesaurus ValueDomain-2)
    C0205462 (UMLS 2011AA ValueDomain-2)
    Item Group
    Footer Module
    Person Completing Form
    Item
    Completed by
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (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)
    Back to the top of the page 

    Help

    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