ID
9115
Descripción
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
Palabras clave
Versiones (2)
- 27/8/12 27/8/12 -
- 9/1/15 9/1/15 - Martin Dugas
Subido en
9 de enero de 2015
DOI
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Licencia
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)
Descripción
Concomitant Therapy:
Descripción
TypeofTherapy
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Metathesaurus Property
- C0332307
Descripción
AgentName
Tipo de datos
text
Descripción
AgentTotalDose(perday)
Tipo de datos
float
Descripción
AgentAdminRoute
Tipo de datos
text
Descripción
AgentBeginDate
Tipo de datos
date
Descripción
SignificantMedicalHistory,ConcomitantDiseasesand/orRelevantMedicalConditions
Tipo de datos
text
Descripción
Reasonforseriousness
Tipo de datos
text
Descripción
Otherspecify(seriousness)
Tipo de datos
text
Descripción
CTCAdverseEventAttributionCode
Tipo de datos
text
Descripción
ToxicityGradeforEventsthoughttobeatleastpossiblyrelated
Tipo de datos
text
Descripción
IntheInvestigator'sopinion,theEventwasmostlikelydueto:
Tipo de datos
text
Descripción
InvestigatorSignature
Tipo de datos
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Descripción
InvestigatorSignature
Tipo de datos
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Descripción
TreatingPhysician
Tipo de datos
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
Descripción
PhoneNumber
Tipo de datos
float
Descripción
FaxNumber
Tipo de datos
float
Descripción
InvestigatorSignatureDate
Tipo de datos
date
Descripción
Ccrr Module For Serious Adverse Event Form (form 24-sae-a)
Descripción
PatientStudyID,CoordinatingGroup
Tipo de datos
text
Descripción
Patient Initials
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Descripción
PatientBirthDate
Tipo de datos
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Descripción
MainMemberInstitution/Affiliate
Tipo de datos
text
Descripción
ParticipatingGroupCode
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
Descripción
Dateofinitialreport
Tipo de datos
text
Descripción
PatientFollow-upAssessmentReportDate
Tipo de datos
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
Similar models
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)