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ID

9123

Beskrivning

Breast Radiotherapy Form (Form 24-R) 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=B0EA70C7-465E-6363-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA70C7-465E-6363-E034-0003BA12F5E7

Nyckelord

  1. 2012-08-27 2012-08-27 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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    Breast Cancer NCT00659373 Treatment - Breast Radiotherapy Form (Form 24-R) - 2073924v3.0

    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.

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

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

    Patient ID No. (Study No.)
    Beskrivning

    PatientStudyID,CoordinatingGroup

    Datatyp

    text

    Patient Initials (f m fl sl)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient's Date of Birth (day)
    Beskrivning

    PatientBirthDate

    Datatyp

    date

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

    ParticipatingCenter/Affiliate

    Datatyp

    text

    Center Code
    Beskrivning

    ParticipatingGroupCode

    Datatyp

    text

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

    BreastSideAssessmentSite

    Datatyp

    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)?
    Beskrivning

    Didthepatientreceiveintraoperativeradiotherapy(IORT)?

    Datatyp

    boolean

    Did patient start adjuvant postoperative radiotherapy?
    Beskrivning

    Didpatientstartadjuvantpostoperativeradiotherapy?

    Datatyp

    boolean

    Date postoperative radiotherapy started (day month year)
    Beskrivning

    Datepostoperativeradiotherapystarted

    Datatyp

    text

    Date postoperative radiotherapy ended (day month year)
    Beskrivning

    Datepostoperativeradiotherapyended

    Datatyp

    text

    Total postoperative dose given without boost (cGy)
    Beskrivning

    Totalpostoperativedosegivenwithoutboost

    Datatyp

    text

    Postoperative radiotherapy fields (select all areas that apply)
    Beskrivning

    RTSite

    Datatyp

    text

    Other, ( please specify)
    Beskrivning

    RTSite,Other

    Datatyp

    text

    Was postoperative radiotherapy boost given?
    Beskrivning

    Waspostoperativeradiotherapyboostgiven?

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Total Dose to Boost Field(s) (cGy)
    Beskrivning

    BrachytherapyTotalDose,Boost

    Datatyp

    float

    For those patients who did not start adjuvant radiotherapy, please give reason (select one box only)
    Beskrivning

    Forthosepatientswhodidnotstartadjuvantradiotherapy,pleasegivereason

    Datatyp

    text

    Other, (please specify)
    Beskrivning

    Other,

    Datatyp

    text

    Investigator Signature (/Designee)
    Beskrivning

    Investigator Signature

    Datatyp

    text

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

    Investigator Signature Date

    Datatyp

    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

    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.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Ccrr Module For Breast Radiotherapy Form (form 24-r)
    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
    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)
    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)?
    boolean
    Didpatientstartadjuvantpostoperativeradiotherapy?
    Item
    Did patient start adjuvant postoperative radiotherapy?
    boolean
    Datepostoperativeradiotherapystarted
    Item
    Date postoperative radiotherapy started (day month year)
    text
    Datepostoperativeradiotherapyended
    Item
    Date postoperative radiotherapy ended (day month year)
    text
    Totalpostoperativedosegivenwithoutboost
    Item
    Total postoperative dose given without boost (cGy)
    text
    Item
    Postoperative radiotherapy fields (select all areas that apply)
    text
    Code List
    Postoperative radiotherapy fields (select all areas that apply)
    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, ( please specify)
    text
    Waspostoperativeradiotherapyboostgiven?
    Item
    Was postoperative radiotherapy boost given?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    BrachytherapyTotalDose,Boost
    Item
    Total Dose to Boost Field(s) (cGy)
    float
    Item
    For those patients who did not start adjuvant radiotherapy, please give reason (select one box only)
    text
    Code List
    For those patients who did not start adjuvant radiotherapy, please give reason (select one box only)
    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, (please specify)
    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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