ID

8982

Beschrijving

Gynecologic Procedures Form (Form 24-GYN) 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=B12178AE-C51B-4967-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12178AE-C51B-4967-E034-0003BA12F5E7

Trefwoorden

Versies (2)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Gynecologic Procedures Form (Form 24-GYN) - 2074074v3.0

Engels

GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulieren  
Report All Gynecologic Procedures Which Apply:
Beschrijving

Report All Gynecologic Procedures Which Apply:

Transvaginal ultrasound Date (D M Y)
Beschrijving

TransvaginalultrasoundDate

Datatype

text

Abdominal/pelvic ultrasound Date (D M Y)
Beschrijving

DiagnosticImagingAbdominalPelvicUltrasoundImagingPerformedDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property-2
C25342
UMLS 2011AA Property-2
C0000726
NCI Thesaurus Property-3
C17230
UMLS 2011AA Property-3
C0041618
NCI Thesaurus Property-4
C25399
UMLS 2011AA Property-4
C0030797
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Other imaging Date (D M Y)
Beschrijving

OtherimagingDate

Datatype

text

Other imaging, specify site and type of image
Beschrijving

Otherimaging,specifysiteandtypeofimage

Datatype

text

Screening endometrial sampling Date (D M Y)
Beschrijving

Endometrialsamplingdate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Hysterectomy (date) (D M Y)
Beschrijving

HysterectomyPerformedDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15256
UMLS 2011AA ObjectClass
C0020699
Unilateral oophorectomy Date (D M Y)
Beschrijving

UnilateralOophorectomyPerformedDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C28012
UMLS 2011AA ObjectClass
C0205092
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass-2
C15291
UMLS 2011AA ObjectClass-2
C0029936
Bilateral oophorectomy Date (D M Y)
Beschrijving

BilateraloophorectomyDate

Datatype

text

Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
Beschrijving

Reasonhysterectomyoroophorectomywasdone

Datatype

text

Other, specify (hysterectomy done)
Beschrijving

HysterectomyPerformedSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15256
UMLS 2011AA ObjectClass
C0020699
Date (day month year)
Beschrijving

InvestigatorSignatureDate

Datatype

date

Date (day month year)
Beschrijving

InvestigatorSignatureDate

Datatype

date

Pathologic Diagnosis
Beschrijving

PathologicDiagnosis

Datatype

text

Ccrr Module For Gynecologic Procedures Form (form 24-gyn)
Beschrijving

Ccrr Module For Gynecologic Procedures Form (form 24-gyn)

Patient ID Number (Study No.)
Beschrijving

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Initials (f m fl sl)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth (day)
Beschrijving

PatientBirthDate

Datatype

date

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

MainMemberInstitution/Affiliate

Datatype

text

Center Code
Beschrijving

ParticipatingGroupCode

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
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Similar models

GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Report All Gynecologic Procedures Which Apply:
TransvaginalultrasoundDate
Item
Transvaginal ultrasound Date (D M Y)
text
DiagnosticImagingAbdominalPelvicUltrasoundImagingPerformedDate
Item
Abdominal/pelvic ultrasound Date (D M Y)
date
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25342 (NCI Thesaurus Property-2)
C0000726 (UMLS 2011AA Property-2)
C17230 (NCI Thesaurus Property-3)
C0041618 (UMLS 2011AA Property-3)
C25399 (NCI Thesaurus Property-4)
C0030797 (UMLS 2011AA Property-4)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
OtherimagingDate
Item
Other imaging Date (D M Y)
text
Otherimaging,specifysiteandtypeofimage
Item
Other imaging, specify site and type of image
text
Endometrialsamplingdate
Item
Screening endometrial sampling Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
HysterectomyPerformedDate
Item
Hysterectomy (date) (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
UnilateralOophorectomyPerformedDate
Item
Unilateral oophorectomy Date (D M Y)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C28012 (NCI Thesaurus ObjectClass)
C0205092 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15291 (NCI Thesaurus ObjectClass-2)
C0029936 (UMLS 2011AA ObjectClass-2)
BilateraloophorectomyDate
Item
Bilateral oophorectomy Date (D M Y)
text
Item
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
text
CL.2
Code List
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
CL Item
Ovarian Cancer Prevention (Ovarian cancer prevention)
CL Item
Breast Cancer Prevention (Breast cancer prevention)
C15553 (NCI Thesaurus)
C0281189 (UMLS 2011AA)
CL Item
Benign Gynecologic Condition (Benign gynecologic condition)
CL Item
Pre-malignancy (Pre-malignancy)
CL Item
Borderline Ovarian Tumor (Borderline ovarian tumor)
CL046614 (NCI Metathesaurus)
CL Item
Invasive Cancer (Invasive cancer)
CL Item
Other, Specify (Other, specify)
HysterectomyPerformedSpecify
Item
Other, specify (hysterectomy done)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15256 (NCI Thesaurus ObjectClass)
C0020699 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
InvestigatorSignatureDate
Item
Date (day month year)
date
Item
Pathologic Diagnosis
text
CL.1
Code List
Pathologic Diagnosis
CL Item
Negative (Negative)
CL Item
Invasive cancer (Invasive cancer)
CL Item
In situ cancer (In situ cancer)
CL Item
Simple cystic hyperplasia without atypia (Simple cystic hyperplasia without atypia)
CL Item
Simple cystic hyperplasia with atypia (Simple cystic hyperplasia with atypia)
CL Item
Complex/adenomatous hyperplasia without atypia (Complex/adenomatous hyperplasia without atypia)
CL Item
Complex/adenomatoushyperplasia with atypia (Complex/adenomatoushyperplasia with atypia)
CL Item
Non-diagnostic (Non-diagnostic)
Item Group
Ccrr Module For Gynecologic Procedures Form (form 24-gyn)
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
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