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ID

8726

Description

Z1041: Missed Visit 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=211E1232-0FB6-645F-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211E1232-0FB6-645F-E044-0003BA3F9857

Keywords

  1. 8/26/12 8/26/12 -
  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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    Breast Cancer NCT00513292 Follow-Up - Z1041: Missed Visit Form - 2533711v1.0

    No Instruction available.

    1. StudyEvent: Z1041: Missed Visit 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
    Patient ID (Pt. 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

    Missed Visit Date (Year Month e.g., JAN Day)
    Description

    PatientAbsentVisitDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    Reason patient missed visit (Mark only one.)
    Description

    PatientAbsentVisitReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    Other, specify
    Description

    PatientAbsentVisitSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property-2
    C25716
    UMLS 2011AA Property-2
    C0545082
    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

    Similar models

    No Instruction available.

    1. StudyEvent: Z1041: Missed Visit 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)
    Code List
    Visit
    CL Item
    C1d21 (C1D21)
    CL Item
    C2d21 (C2D21)
    CL Item
    C3d21 (C3D21)
    CL Item
    C4d21 (C4D21)
    CL Item
    C5d21 (C5D21)
    CL Item
    C6d21 (C6D21)
    CL Item
    C7d21 (C7D21)
    CL Item
    C8d21 (C8D21)
    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)
    Patient Study ID
    Item
    Patient ID (Pt. 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
    PatientAbsentVisitDate
    Item
    Missed Visit Date (Year Month e.g., JAN Day)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-2)
    Item
    Reason patient missed visit (Mark only one.)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-2)
    Code List
    Reason patient missed visit (Mark only one.)
    CL Item
    Health Reasons (Health reasons)
    CL Item
    Distance From Home To Clinical Site (Distance from home to clinical site)
    CL Item
    Scheduling Difficulties (Scheduling difficulties)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PatientAbsentVisitSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property-2)
    C0545082 (UMLS 2011AA Property-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)

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