ID

9020

Description

Surgery Form (Form 24-C) 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=B0E98146-9F96-636E-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0E98146-9F96-636E-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Surgery Form (Form 24-C) - 2074148v3.0

English

SURGERY FORM (Form 24-C) Instructions: This form is to be completed and submitted one month after final surgery. 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 Surgery Form (form 24-c)
Description

Ccrr Module For Surgery Form (form 24-c)

Patient ID No. (Study No.)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
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 (day)
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 (Ver.#1)
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
Date of Initial Pathologic Diagnosis (D M Y)
Description

InitialDiagnosisDate

Data type

date

Type (LTM = less than mastectomy)
Description

SurgicalProcedureBreastNeoplasmPerformedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property-2
C2910
UMLS 2011AA Property-2
C0042875
Other, (specify)
Description

Other,

Data type

text

Surgery Date (D M Y)
Description

SurgeryDate

Data type

date

PATHOLOGIC FINDINGS
Description

PATHOLOGICALFINDINGS

Data type

text

Was sentinel node biopsy performed?
Description

SentinelNodeBiopsyInd

Data type

boolean

Sentinel Node Biopsy Date (D M Y)
Description

SentinelNodeBiopsyDate

Data type

date

Was axillary dissection performed?
Description

AxillaryDissectionInd

Data type

boolean

Date of axillary dissection (D M Y)
Description

AxillaryDissectionDate

Data type

date

Investigator Signature (/Designee)
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

SURGERY FORM (Form 24-C) Instructions: This form is to be completed and submitted one month after final surgery. 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 Surgery Form (form 24-c)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (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)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code (Ver.#1)
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)
InitialDiagnosisDate
Item
Date of Initial Pathologic Diagnosis (D M Y)
date
Item
Type (LTM = less than mastectomy)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C2910 (NCI Thesaurus Property-2)
C0042875 (UMLS 2011AA Property-2)
CL.2
Code List
Type (LTM = less than mastectomy)
CL Item
Core Biopsy (Core biopsy)
C15680 (NCI Thesaurus)
C1318309 (UMLS 2011AA)
CL Item
Fine Needle Aspiration (Fine needle aspiration)
CL Item
Ltm: Lump Excision/complete Local Excision (LTM: lump excision/complete local excision)
CL Item
Ltm: Partial Mastectomy/quadrantectomy (LTM: partial mastectomy/quadrantectomy)
CL Item
Ltm: Re-excision For Unclear Or Positive Margins (LTM: re-excision for unclear or positive margins)
CL Item
Ltm: Subcutaneous Mastectomy (LTM: subcutaneous mastectomy)
CL Item
Ltm: Subtotal Mastectomy (LTM: subtotal mastectomy)
CL Item
Mastectomy (Mastectomy)
C15277 (NCI Thesaurus)
C0024881 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Other Biopsy (Other biopsy)
Other,
Item
Other, (specify)
text
SurgeryDate
Item
Surgery Date (D M Y)
date
Item
PATHOLOGIC FINDINGS
text
CL.3
Code List
PATHOLOGIC FINDINGS
CL Item
No Malignancy (No malignancy)
CL Item
Suspicious For Malignancy (Suspicious for malignancy)
CL Item
Malignant Cells On Fna (Malignant cells on FNA)
CL Item
In Situ Without Invasion (IN SITU without invasion)
CL Item
Invasive Cancer (Invasive cancer)
SentinelNodeBiopsyInd
Item
Was sentinel node biopsy performed?
boolean
SentinelNodeBiopsyDate
Item
Sentinel Node Biopsy Date (D M Y)
date
AxillaryDissectionInd
Item
Was axillary dissection performed?
boolean
AxillaryDissectionDate
Item
Date of axillary dissection (D M Y)
date
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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