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ID

8875

Description

CALGB: 80203 BACKGROUND INFORMATION FORM Fluorouracil and Leucovorin Plus Either Irinotecan or Oxaliplatin With or Without Cetuximab in Treating Patients With Previously Untreated Metastatic Adenocarcinoma of the Colon or Rectum Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFD5AAD1-D500-39A2-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFD5AAD1-D500-39A2-E034-0003BA12F5E7

Mots-clés

  1. 27/08/2012 27/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy

Modèle Commentaires :

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    Colorectal Cancer NCT00077233 Demographic - CALGB: 80203 BACKGROUND INFORMATION FORM - 2171121v3.0

    No Instruction available.

    1. StudyEvent: CALGB: 80203 BACKGROUND INFORMATION FORM
      1. No Instruction available.
    Ccrr Module For Calgb: 80203 Background Information Form
    Description

    Ccrr Module For Calgb: 80203 Background Information Form

    Patient Hospital No.
    Description

    Medical Record Number

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C1301894 (Medical record number)
    SNOMED
    398225001
    LOINC
    MTHU047637
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25261 (undefined)
    NCI Thesaurus Property-2
    C25198 (undefined)
    Institution/Affiliate
    Description

    Institution Name

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass-2
    C21541 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    NCI Thesaurus ValueDomain-2
    C21541 (undefined)
    Participating Group Protocol No.
    Description

    ParticipatingGroupProtocolNo.

    Type de données

    text

    Participating Group Patient ID
    Description

    ParticipatingGroupPatientID

    Type de données

    text

    Today's date
    Description

    Today'sDate

    Type de données

    text

    What is the highest grade you finished in school? (Mark one with an X)
    Description

    Whatisthehighestgradeyoufinishedinschool?

    Type de données

    text

    What is your marital status? (Mark one with an X)
    Description

    Whatisyourmaritalstatus?

    Type de données

    text

    With whom do you live? (Mark all that apply with an X)
    Description

    Withwhomdoyoulive?

    Type de données

    text

    What is your current employment status? (Mark all that apply with an X)
    Description

    Whatisyourcurrentemploymentstatus?

    Type de données

    text

    Patient Initials
    Description

    PatientInitials

    Type de données

    text

    Participating Group
    Description

    ParticipatingGroup

    Type de données

    text

    Other, specify
    Description

    Other,specify

    Type de données

    text

    Other relative, specify
    Description

    Otherrelative,specify

    Type de données

    text

    Other, specify
    Description

    Other,specify

    Type de données

    text

    Similar models

    No Instruction available.

    1. StudyEvent: CALGB: 80203 BACKGROUND INFORMATION FORM
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Ccrr Module For Calgb: 80203 Background Information Form
    Medical Record Number
    Item
    Patient Hospital No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301894 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    ParticipatingGroupProtocolNo.
    Item
    Participating Group Protocol No.
    text
    ParticipatingGroupPatientID
    Item
    Participating Group Patient ID
    text
    Today'sDate
    Item
    Today's date
    text
    Item
    What is the highest grade you finished in school? (Mark one with an X)
    text
    Code List
    What is the highest grade you finished in school? (Mark one with an X)
    CL Item
    1-8 Grades (1-8 grades)
    CL Item
    9-11 Grades (9-11 grades)
    CL Item
    High School Graduate (High School graduate)
    C67136 (NCI Thesaurus)
    C0870649 (UMLS 2011AA)
    CL Item
    Some College (Some college)
    CL Item
    Junior College Degree (Junior college degree)
    CL Item
    College Degree (b.a./b.s.) (College degree (B.A./B.S.))
    CL Item
    Some Post-college Work (Some post-college work)
    CL Item
    Advanced Degree (Advanced degree)
    Item
    What is your marital status? (Mark one with an X)
    text
    Code List
    What is your marital status? (Mark one with an X)
    CL Item
    Single, Never Married (Single, never married)
    CL Item
    Married (Married)
    C0555047 (NCI Metathesaurus)
    CL Item
    Separated (Separated)
    C51777 (NCI Thesaurus)
    C0086972 (UMLS 2011AA)
    CL Item
    Divorced (Divorced)
    C0086170 (NCI Metathesaurus)
    CL Item
    Widowed (Widowed)
    C51775 (NCI Thesaurus)
    C0206275 (UMLS 2011AA)
    Item
    With whom do you live? (Mark all that apply with an X)
    text
    Code List
    With whom do you live? (Mark all that apply with an X)
    CL Item
    Spouse/partner (Spouse/Partner)
    CL Item
    Children Aged 18 Years Or Younger (Children aged 18 years or younger)
    CL Item
    Children Aged 19 Years Or Older (Children aged 19 years or older)
    CL Item
    Parent(s)/parent(s)-in-law (Parent(s)/Parent(s)-In-Law)
    CL Item
    Other Relative, Specify (Other relative, specify)
    CL Item
    Live Alone (Live alone)
    CL Item
    Other, Specify (Other, specify)
    CL Item
    Other Relative, Specify (Other relative, specify)
    Item
    What is your current employment status? (Mark all that apply with an X)
    text
    Code List
    What is your current employment status? (Mark all that apply with an X)
    CL Item
    Employed 32 Hours Or More Per Week (Employed 32 hours or more per week)
    CL Item
    Employed less than 32 hours per week (Employed less than 32 hours per week)
    CL Item
    Full-time Student (Full-time student)
    CL Item
    Part-time Student (Part-time student)
    CL Item
    Homemaker (Homemaker)
    C0555052 (NCI Metathesaurus)
    CL Item
    On Medical Leave (On medical leave)
    CL Item
    Disabled (Disabled)
    C63367 (NCI Thesaurus)
    C1880351 (UMLS 2011AA)
    CL Item
    Unemployed (Unemployed)
    C0425086 (NCI Metathesaurus)
    CL Item
    Retired (Retired)
    CL Item
    Other, Specify (Other, specify)
    PatientInitials
    Item
    Patient Initials
    text
    ParticipatingGroup
    Item
    Participating Group
    text
    Other,specify
    Item
    Other, specify
    text
    Otherrelative,specify
    Item
    Other relative, specify
    text
    Other,specify
    Item
    Other, specify
    text

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