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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