ID

8957

Description

Bilateral Hormone Receptor Form (Form 24-BF) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01609FC5-4143-11A6-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=01609FC5-4143-11A6-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

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Pathology - Bilateral Hormone Receptor Form (Form 24-BF) - 2409866v1.0

English

HORMONE RECEPTOR FORM (Form 24-F) Instructions: This form is to be completed and submitted after hormone receptor analysis is performed, within one done at first recurrence. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

1 forms  
Ccrr Module For Hormone Receptor Form (form 24-f)
Description

Ccrr Module For Hormone Receptor Form (form 24-f)

Patient ID No. (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Description

ParticipatingCenter/Affiliate

Data type

text

Center Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
This form is being completed for
Description

BreastSideAssessmentSite

Data type

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus Property-2
C25306
UMLS 2011AA Property-2
C0441987
Specimen ID Number (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

SpecimenID

Data type

float

Date Specimen Collected (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

SpecimenCollectionDate

Data type

date

ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Description

EstrogenReceptorPositivePercentage

Data type

float

Measurement units
  • %
Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
%
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Description

ProgesteroneReceptorPositivePercentage

Data type

float

Measurement units
  • %
Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C17075
UMLS 2011AA ObjectClass
C0034833
NCI Thesaurus Property
C25554
UMLS 2011AA Property
C0441889
%
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

ERStatus

Data type

text

PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
Description

PgRStatus

Data type

text

Investigator Signature
Description

Investigator Signature

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
Date
Description

Investigator Signature Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C2346576
NCI Thesaurus Property
C25678
UMLS CUI-2
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
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Similar models

HORMONE RECEPTOR FORM (Form 24-F) Instructions: This form is to be completed and submitted after hormone receptor analysis is performed, within one done at first recurrence. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Hormone Receptor Form (form 24-f)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
Patient Initials
Item
Patient Initials (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property-2)
C0441987 (UMLS 2011AA Property-2)
CL.1
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
SpecimenID
Item
Specimen ID Number (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
float
SpecimenCollectionDate
Item
Date Specimen Collected (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
date
EstrogenReceptorPositivePercentage
Item
ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
ProgesteroneReceptorPositivePercentage
Item
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0034833 (UMLS 2011AA ObjectClass)
C25554 (NCI Thesaurus Property)
C0441889 (UMLS 2011AA Property)
Item
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
CL.2
Code List
ER status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
text
CL.3
Code List
PgR status (CCRR MODULE FOR Hormone Receptor Form Form 24-F)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Investigator Signature
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
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