ID
9115
Beschrijving
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
Trefwoorden
Versies (2)
- 27-08-12 27-08-12 -
- 09-01-15 09-01-15 - Martin Dugas
Geüploaded op
9 januari 2015
DOI
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Licentie
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)
Beschrijving
Concomitant Therapy:
Beschrijving
TypeofTherapy
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Metathesaurus Property
- C0332307
Beschrijving
AgentName
Datatype
text
Beschrijving
AgentTotalDose(perday)
Datatype
float
Beschrijving
AgentAdminRoute
Datatype
text
Beschrijving
AgentBeginDate
Datatype
date
Beschrijving
SignificantMedicalHistory,ConcomitantDiseasesand/orRelevantMedicalConditions
Datatype
text
Beschrijving
Reasonforseriousness
Datatype
text
Beschrijving
Otherspecify(seriousness)
Datatype
text
Beschrijving
CTCAdverseEventAttributionCode
Datatype
text
Beschrijving
ToxicityGradeforEventsthoughttobeatleastpossiblyrelated
Datatype
text
Beschrijving
IntheInvestigator'sopinion,theEventwasmostlikelydueto:
Datatype
text
Beschrijving
InvestigatorSignature
Datatype
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Beschrijving
InvestigatorSignature
Datatype
text
Alias
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Beschrijving
TreatingPhysician
Datatype
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
Beschrijving
PhoneNumber
Datatype
float
Beschrijving
FaxNumber
Datatype
float
Beschrijving
InvestigatorSignatureDate
Datatype
date
Beschrijving
Ccrr Module For Serious Adverse Event Form (form 24-sae-a)
Beschrijving
PatientStudyID,CoordinatingGroup
Datatype
text
Beschrijving
Patient Initials
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Beschrijving
PatientBirthDate
Datatype
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Beschrijving
MainMemberInstitution/Affiliate
Datatype
text
Beschrijving
ParticipatingGroupCode
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
Beschrijving
Dateofinitialreport
Datatype
text
Beschrijving
PatientFollow-upAssessmentReportDate
Datatype
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)