ID

9013

Descrizione

Bilateral Breast Radiotherapy Form (Form 24-BR) 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=0162063B-84EB-2286-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0162063B-84EB-2286-E044-0003BA3F9857

Keywords

versioni (2)
  1. 27/08/12 27/08/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Bilateral Breast Radiotherapy Form (Form 24-BR) - 2411259v1.0

Inglese

BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. 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 moduli  
Ccrr Module For Breast Radiotherapy Form (form 24-r)
Descrizione

Ccrr Module For Breast Radiotherapy Form (form 24-r)

Patient ID No. (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

PatientStudyID,CoordinatingGroup

Tipo di dati

text

Patient Initials (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
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's Date of Birth (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

PatientBirthDate

Tipo di dati

date

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

ParticipatingCenter/Affiliate

Tipo di dati

text

Center Code
Descrizione

ParticipatingGroupCode

Tipo di dati

text

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

BreastSideAssessmentSite

Tipo di dati

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
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Didthepatientreceiveintraoperativeradiotherapy(IORT)?

Tipo di dati

boolean

Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Didpatientstartadjuvantpostoperativeradiotherapy?

Tipo di dati

boolean

Date postoperative radiotherapy started (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Datepostoperativeradiotherapystarted

Tipo di dati

text

Date postoperative radiotherapy ended (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Datepostoperativeradiotherapyended

Tipo di dati

text

Total postoperative dose given without boost (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Totalpostoperativedosegivenwithoutboost

Tipo di dati

text

Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

RTSite

Tipo di dati

text

Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

RTSite,Other

Tipo di dati

text

Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Waspostoperativeradiotherapyboostgiven?

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Total Dose to Boost Field(s) (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

BrachytherapyTotalDose,Boost

Tipo di dati

float

For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Forthosepatientswhodidnotstartadjuvantradiotherapy,pleasegivereason

Tipo di dati

text

Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Descrizione

Other,

Tipo di dati

text

Investigator Signature (/Designee)
Descrizione

Investigator Signature

Tipo di dati

text

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

Investigator Signature Date

Tipo di dati

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

BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. 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 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Ccrr Module For Breast Radiotherapy Form (form 24-r)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Patient Initials
Item
Patient Initials (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
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 Breast Radiotherapy Form Form 24-R)
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)
Didthepatientreceiveintraoperativeradiotherapy(IORT)?
Item
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
Didpatientstartadjuvantpostoperativeradiotherapy?
Item
Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
Datepostoperativeradiotherapystarted
Item
Date postoperative radiotherapy started (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Datepostoperativeradiotherapyended
Item
Date postoperative radiotherapy ended (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Totalpostoperativedosegivenwithoutboost
Item
Total postoperative dose given without boost (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Item
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.4
Code List
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Breast (Breast)
CL Item
Supraclavicular lymph nodes (Supraclavicular lymph nodes)
CL Item
Internal mammary lymph nodes (Internal mammary lymph nodes)
CL Item
Chest wall (Chest wall)
CL Item
Axilla (Axilla)
CL Item
Other, please specify (Other, please specify)
RTSite,Other
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Waspostoperativeradiotherapyboostgiven?
Item
Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
BrachytherapyTotalDose,Boost
Item
Total Dose to Boost Field(s) (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
float
Item
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.6
Code List
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Patient Refused (Patient refused)
CL Item
Initially Planned, But Physician Later Advised Against (Initially planned, but physician later advised against)
CL Item
Early Recurrence (Early recurrence)
CL Item
Early Death (Early death)
CL Item
Other, Please Specify (Other, please specify)
Other,
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Investigator Signature
Item
Investigator Signature (/Designee)
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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