ID
9115
Beschreibung
Serious Adverse Event Form (Form 24-SAE-A) 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=B111F21A-A960-319C-E034-0003BA12F5E7
Link
Stichworte
Versionen (2)
- 27.08.12 27.08.12 -
- 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am
9. Januar 2015
DOI
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Lizenz
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Toxicity - Serious Adverse Event Form (Form 24-SAE-A) - 2072974v3.0
SERIOUS ADVERSE EVENT FORM (Form 24-SAE-A) Instructions: Fax Section A within 24 hours in the case of a serious adverse event. Fax Section B within 15 days of initial report and/or for definitive SAE outcome. 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.
- StudyEvent: Serious Adverse Event Form (Form 24-SAE-A)
Beschreibung
Concomitant Therapy:
Beschreibung
TypeofTherapy
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Metathesaurus Property
- C0332307
Beschreibung
AgentName
Datentyp
text
Beschreibung
AgentTotalDose(perday)
Datentyp
float
Beschreibung
AgentAdminRoute
Datentyp
text
Beschreibung
AgentBeginDate
Datentyp
date
Beschreibung
SignificantMedicalHistory,ConcomitantDiseasesand/orRelevantMedicalConditions
Datentyp
text
Beschreibung
Reasonforseriousness
Datentyp
text
Beschreibung
Otherspecify(seriousness)
Datentyp
text
Beschreibung
CTCAdverseEventAttributionCode
Datentyp
text
Beschreibung
ToxicityGradeforEventsthoughttobeatleastpossiblyrelated
Datentyp
text
Beschreibung
IntheInvestigator'sopinion,theEventwasmostlikelydueto:
Datentyp
text
Beschreibung
InvestigatorSignature
Datentyp
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Beschreibung
InvestigatorSignature
Datentyp
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Beschreibung
TreatingPhysician
Datentyp
text
Alias
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ObjectClass
- C25741
- UMLS 2011AA ObjectClass
- C0031831
- NCI Thesaurus ObjectClass-2
- C25705
- UMLS 2011AA ObjectClass-2
- C1522326
Beschreibung
PhoneNumber
Datentyp
float
Beschreibung
FaxNumber
Datentyp
float
Beschreibung
InvestigatorSignatureDate
Datentyp
date
Beschreibung
Ccrr Module For Serious Adverse Event Form (form 24-sae-a)
Beschreibung
PatientStudyID,CoordinatingGroup
Datentyp
text
Beschreibung
Patient Initials
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Beschreibung
PatientBirthDate
Datentyp
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Beschreibung
MainMemberInstitution/Affiliate
Datentyp
text
Beschreibung
ParticipatingGroupCode
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
Beschreibung
Dateofinitialreport
Datentyp
text
Beschreibung
PatientFollow-upAssessmentReportDate
Datentyp
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property-2
- C16033
- UMLS 2011AA Property-2
- C1522577
- NCI Thesaurus Property-3
- C25375
- UMLS 2011AA Property-3
- C0684224
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Ähnliche Modelle
SERIOUS ADVERSE EVENT FORM (Form 24-SAE-A) Instructions: Fax Section A within 24 hours in the case of a serious adverse event. Fax Section B within 15 days of initial report and/or for definitive SAE outcome. 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.
- StudyEvent: Serious Adverse Event Form (Form 24-SAE-A)
C0011008 (UMLS 2011AA ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C0332307 (NCI Metathesaurus Property)
C0445356 (UMLS 2011AA)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C16033 (NCI Thesaurus Property-2)
C1522577 (UMLS 2011AA Property-2)
C25375 (NCI Thesaurus Property-3)
C0684224 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
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