To be completed on all patients annually until death after first disease progression. To be submitted electronically within 8 weeks of the date the patient was seen at the clinic.

1 moduli

StudyEvent: NCIC OV 21 Short Follow-Up Report Form
1. To be completed on all patients annually until death after first disease progression. To be submitted electronically within 8 weeks of the date the patient was seen at the clinic.

Patient Information

Descrizione

Patient Information

NCIC Patient ID (NCIC CTG Patient Serial Number issued at the time of randomization)

Descrizione

PatientNationalCancerInstituteofCanadaIdentifierNumber

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

NCI Thesaurus ObjectClass: C16960

UMLS 2011AA ObjectClass: C0030705

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus Property-2: C25582

UMLS 2011AA Property-2: C1513884

Patient Initials (first-middle-last)

Descrizione

Patient Initials

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C2986440

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25536

Patient Hospital No. (if permitted by REB)

Descrizione

Medical Record Number

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C1301894

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25261

NCI Thesaurus Property-2: C25198

Investigator No.

Descrizione

PhysicianInvestigatorIdentifierNumber

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus ObjectClass: C25741

UMLS 2011AA ObjectClass: C0031831

NCI Thesaurus ObjectClass-2: C17089

UMLS 2011AA ObjectClass-2: C0035173

Investigator First Name

Descrizione

InvestigatorFirstName

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS 2011AA ValueDomain: C1547383

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus Property-2: C25509

UMLS 2011AA Property-2: C1279901

NCI Thesaurus ObjectClass: C17089

UMLS 2011AA ObjectClass: C0035173

Investigator Middle Name

Descrizione

TreatingPhysicianMiddleName

Tipo di dati

text

Alias

NCI Thesaurus ObjectClass: C25741

UMLS 2011AA ObjectClass: C0031831

NCI Thesaurus ObjectClass-2: C25705

UMLS 2011AA ObjectClass-2: C1522326

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus Property-2: C25569

UMLS 2011AA Property-2: C0444598

NCI Thesaurus ValueDomain: C25191

UMLS 2011AA ValueDomain: C1547383

Investigator Last Name

Descrizione

InvestigatorLastName

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS 2011AA ValueDomain: C1547383

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus ObjectClass: C17089

UMLS 2011AA ObjectClass: C0035173

NCI Thesaurus Property-2: C25551

UMLS 2011AA Property-2: C1517741

Physical Exam

Descrizione

Physical Exam

Date of Assessment (yyyy-mmm-dd)

Descrizione

Assessment Date

Tipo di dati

date

Alias

NCI Thesaurus ValueDomain: C25164

UMLS CUI-1: C2985720

NCI Thesaurus ObjectClass: C25367

NCI Thesaurus ValueDomain-2: C25367

NCI Thesaurus Property: C38000

Weight (kg)

Descrizione

Patient Weight

Tipo di dati

float

Unità di misura

Alias

NCI Thesaurus ValueDomain: C25209

UMLS CUI-1: C0005910

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25208

Performance Status (ECOG)

Descrizione

ECOG Performance Status

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25664

UMLS CUI-1: C1520224

NCI Thesaurus Property: C25367

NCI Thesaurus ValueDomain-2: C25491

NCI Thesaurus ObjectClass: C20641

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)

Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)

Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)

Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)

Patient's Vital Status (check all that apply)

Descrizione

Patient Status

Tipo di dati

text

Alias

NCI Thesaurus ObjectClass: C16960

UMLS CUI-1: C3846084

NCI Thesaurus ValueDomain: C18003

NCI Thesaurus ValueDomain-2: C25688

NCI Thesaurus Property: C25717

Alive (Alive)

Dead (Dead)

Comments

Descrizione

Comments

Descrizione

Research Comments

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25704

UMLS CUI-1: C0947611

NCI Thesaurus ObjectClass: C15319

NCI Thesaurus Property: C25393

Contact Information

Descrizione

Contact Information

CRA Name

Descrizione

CRAName

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS 2011AA ValueDomain: C1547383

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus ObjectClass: C25465

UMLS 2011AA ObjectClass: C1516627

Phone number

Descrizione

ClinicalResearchAssociatePersonTelephoneNumber

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

NCI Thesaurus ObjectClass: C25190

UMLS 2011AA ObjectClass: C0027361

NCI Thesaurus Property: C25395

UMLS 2011AA Property: C0039457

NCI Thesaurus ObjectClass-2: C25465

UMLS 2011AA ObjectClass-2: C1516627

Fax Number

Descrizione

ClinicalResearchAssociatePersonFaxNumber

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

NCI Thesaurus ObjectClass: C25190

UMLS 2011AA ObjectClass: C0027361

NCI Thesaurus ObjectClass-2: C25465

UMLS 2011AA ObjectClass-2: C1516627

NCI Thesaurus Property: C25210

UMLS 2011AA Property: C0085205

Institution Name

Descrizione

Institution Name

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C1301943

NCI Thesaurus ObjectClass: C21541

NCI Thesaurus ValueDomain-2: C21541

NCI Thesaurus Property: C25364

Ritorna all'inizio della pagina

Similar models

Show recommended models

To be completed on all patients annually until death after first disease progression. To be submitted electronically within 8 weeks of the date the patient was seen at the clinic.

1 moduli

StudyEvent: NCIC OV 21 Short Follow-Up Report Form
1. To be completed on all patients annually until death after first disease progression. To be submitted electronically within 8 weeks of the date the patient was seen at the clinic.

Name

genere

Description | Question | Decode (Coded Value)

Tipo di dati

Alias

Patient Information

Item Group

Patient Information

PatientNationalCancerInstituteofCanadaIdentifierNumber

Item

NCIC Patient ID (NCIC CTG Patient Serial Number issued at the time of randomization)

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25582 (NCI Thesaurus Property-2)
C1513884 (UMLS 2011AA Property-2)

Patient Initials

Item

Patient Initials (first-middle-last)

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Medical Record Number

Item

Patient Hospital No. (if permitted by REB)

text

C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)

PhysicianInvestigatorIdentifierNumber

Item

Investigator No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C0035173 (UMLS 2011AA ObjectClass-2)

InvestigatorFirstName

Item

Investigator First Name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)

TreatingPhysicianMiddleName

Item

Investigator Middle Name

text

C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25569 (NCI Thesaurus Property-2)
C0444598 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)

InvestigatorLastName

Item

Investigator Last Name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus Property-2)
C1517741 (UMLS 2011AA Property-2)

PHYSICAL EXAM

Item Group

Physical Exam

Assessment Date

Item

Date of Assessment (yyyy-mmm-dd)

date

C25164 (NCI Thesaurus ValueDomain)
C2985720 (UMLS CUI-1)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C38000 (NCI Thesaurus Property)

Patient Weight

Item

Weight (kg)

float

C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)

ECOG Performance Status

Item

Performance Status (ECOG)

text

C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)

CL.1

Code List

Performance Status (ECOG)

CL Item

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)

CL Item

Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)

CL Item

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)

CL Item

Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)

CL Item

Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)

Patient Status

Item

Patient's Vital Status (check all that apply)

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

Patient's Vital Status (check all that apply)

CL Item

Alive (Alive)

CL Item

Dead (Dead)

Comments

Item Group

Comments

Research Comments

Item

Comments

text

C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

Contact Information

Item Group

Contact Information

CRAName

Item

CRA Name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25465 (NCI Thesaurus ObjectClass)
C1516627 (UMLS 2011AA ObjectClass)

ClinicalResearchAssociatePersonTelephoneNumber

Item

Phone number

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C25465 (NCI Thesaurus ObjectClass-2)
C1516627 (UMLS 2011AA ObjectClass-2)

ClinicalResearchAssociatePersonFaxNumber

Item

Fax Number

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25465 (NCI Thesaurus ObjectClass-2)
C1516627 (UMLS 2011AA ObjectClass-2)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA 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)

Ritorna all'inizio della pagina