ID

9125

Descrição

Common Toxicity Reporting Form, GOG-0209, Form T Combination Chemotherapy in Treating Patients With Stage III, Stage IV, or Recurrent Endometrial Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B27B3670-3E5E-21DA-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B27B3670-3E5E-21DA-E034-0003BA12F5E7

Palavras-chave

Versões (3)
  1. 27/08/2012 27/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Endometrial Cancer NCT00063999 Toxicity - Common Toxicity Reporting Form, GOG-0209, Form T - 2075711v3.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: Common Toxicity Reporting Form, GOG-0209, Form T
    1. No Instruction available.
Header Module
Descrição

Header Module

Date form originally completed (m d y)
Descrição

Form Completion Date

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Date form amended (m d y)
Descrição

Amendment date

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C0680532
NCI Thesaurus Property
C25250
UMLS CUI-2
C0011008
NCI Thesaurus Property-2
C25416
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Person amending form, last name
Descrição

Person Amending Form

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25190
UMLS CUI-2
C1547383
NCI Thesaurus Property
C25364
Patient Name, Last
Descrição

Last Name

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301584
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25551
Patient Name, First
Descrição

First Name

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1443235
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25509
Patient Study ID
Descrição

Patient Study ID

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Person Completing Form, Last Name
Descrição

Person Completing Form Last Name

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass-2
C25657
UMLS CUI-2
C1301584
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25551
NCI Thesaurus ValueDomain
C25191
Adverse Events - Section 1
Descrição

Adverse Events - Section 1

Current course number (The toxicities listed below occurred following this course of therapy)
Descrição

Cycle Number Chemotherapeutics

Tipo de dados

float

Alias
UMLS CUI-1
C2045829
Has the patient received any transfusions during this course of therapy?
Descrição

Transfusion

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1879316
NCI Thesaurus ObjectClass
C15366
NCI Thesaurus Property
C25382
Was patient hospitalized as a result of reported adverse events?
Descrição

InpatientHospitalizationInd

Tipo de dados

boolean

Were cytokines administered this course?
Descrição

Cytokine Therapy

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0199974
NCI Thesaurus Property
C20464
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property-2
C25382
Yes, specify (cytokines)
Descrição

AgentCytokineAdministeredSpecify

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Has an Adverse Drug Reaction Report been filed?
Descrição

ADRFiledInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25410
UMLS 2011AA ObjectClass
C1521800
NCI Thesaurus Property
C25175
UMLS 2011AA Property
C1522646
Adverse Events - Section 2
Descrição

Adverse Events - Section 2

Peripheral WBC count done?
Descrição

WBC done

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0023508
NCI Thesaurus Property
C12529
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
Peripheral WBC count (1000/mm3 Nadir)
Descrição

Lab,Hematology,WBC

Tipo de dados

float

CTC Adverse Event Grade
Descrição

CTC Adverse Event Grade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS CUI-1
C2985911
NCI Thesaurus Property
C25365
Peripheral WBC count, Date (m d y)
Descrição

Lab,Hematology,WBCDate

Tipo de dados

date

CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
Descrição

CTC Adverse Event Attribution Category

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS CUI-1
C1706735
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25358
Peripheral Granulocytes count done?
Descrição

LaboratoryProcedureAbsoluteNeutrophilCountGranulocyteOutcomeInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C12530
UMLS 2011AA Property-2
C0018183
NCI Thesaurus Property-3
C63321
UMLS 2011AA Property-3
C0948762
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
Descrição

Lab,Hematology,GranulocyteCount

Tipo de dados

float

Peripheral Granulocytes count, Date
Descrição

Lab,Hematology,GranDate

Tipo de dados

date

Peripheral Platelet count done?
Descrição

Platelets

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0005821
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C12520
NCI Thesaurus ObjectClass
C25294
Peripheral Platelet count (mm3 Nadir)
Descrição

HematologyPlateletLabUnspecifiedValue

Tipo de dados

float

Alias
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
Peripheral Platelet count, Date
Descrição

Lab,Hematology,PlateletDate

Tipo de dados

date

Hemoglobin done?
Descrição

Hemoglobin

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0019046
NCI Thesaurus Property
C16676
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
Hemoglobin (G/DL Nadir)
Descrição

Hemoglobin

Tipo de dados

float

Unidades de medida
  • g/dL
Alias
NCI Thesaurus Property
C16676
UMLS CUI-1
C0019046
NCI Thesaurus Property-2
C20200
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
g/dL
Hemoglobin, Date
Descrição

Lab,Hematology,HGBDate

Tipo de dados

date

Adverse Events - Section 3
Descrição

Adverse Events - Section 3

CTC Adverse Event Term
Descrição

CTC Adverse Event Term

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C41331
UMLS CUI-1
C1516728
NCI Thesaurus Property
C25703
UMLS CUI-2
C2826934
CTC Adverse Event Grade
Descrição

CTC Adverse Event Grade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS CUI-1
C2985911
NCI Thesaurus Property
C25365
CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
Descrição

CTC Adverse Event Attribution Category

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS CUI-1
C1706735
NCI Thesaurus ObjectClass
C49704
NCI Thesaurus Property
C25358
COMMENTS
Descrição

Research Comments

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Footer Module
Descrição

Footer Module

Participating Group Code
Descrição

ParticipatingGroupIdentifierCode

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass-2
C17005
UMLS 2011AA ObjectClass-2
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Protocol Number
Descrição

Study Number Participating Group

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Patient Study ID, Participating Group
Descrição

Trial subject ID Participating Group

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Ccrr Module For Common Toxicity Reporting Form, Gog-0209, Form T
Descrição

Ccrr Module For Common Toxicity Reporting Form, Gog-0209, Form T

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No Instruction available.

1 Formulários
  1. StudyEvent: Common Toxicity Reporting Form, GOG-0209, Form T
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Header Module
Form Completion Date
Item
Date form originally completed (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Amendment date
Item
Date form amended (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C0680532 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1547383 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Last Name
Item
Patient Name, Last
text
C25191 (NCI Thesaurus ValueDomain)
C1301584 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
First Name
Item
Patient Name, First
text
C25191 (NCI Thesaurus ValueDomain)
C1443235 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Item Group
Adverse Events - Section 1
Cycle Number Chemotherapeutics
Item
Current course number (The toxicities listed below occurred following this course of therapy)
float
C2045829 (UMLS CUI-1)
Item
Has the patient received any transfusions during this course of therapy?
text
C25180 (NCI Thesaurus ValueDomain)
C1879316 (UMLS CUI-1)
C15366 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
CL.1
Code List
Has the patient received any transfusions during this course of therapy?
CL Item
No Transfusion (No)
CL Item
Transfusion With Red Blood Cells (Yes, red blood cells)
CL Item
Transfusion With Platelets (Yes, platelets)
InpatientHospitalizationInd
Item
Was patient hospitalized as a result of reported adverse events?
boolean
Item
Were cytokines administered this course?
text
C38148 (NCI Thesaurus ValueDomain)
C0199974 (UMLS CUI-1)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
CL.3
Code List
Were cytokines administered this course?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AgentCytokineAdministeredSpecify
Item
Yes, specify (cytokines)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
ADRFiledInd-3
Item
Has an Adverse Drug Reaction Report been filed?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25410 (NCI Thesaurus ObjectClass)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
Item Group
Adverse Events - Section 2
WBC done
Item
Peripheral WBC count done?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0023508 (UMLS CUI-1)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Lab,Hematology,WBC
Item
Peripheral WBC count (1000/mm3 Nadir)
float
CTC Adverse Event Grade
Item
CTC Adverse Event Grade
float
C41331 (NCI Thesaurus ObjectClass)
C2985911 (UMLS CUI-1)
C25365 (NCI Thesaurus Property)
Lab,Hematology,WBCDate
Item
Peripheral WBC count, Date (m d y)
date
Item
CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
text
C25664 (NCI Thesaurus ValueDomain)
C1706735 (UMLS CUI-1)
C49704 (NCI Thesaurus ObjectClass)
C25358 (NCI Thesaurus Property)
CL.10
Code List
CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
CL Item
Unrelated (Unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (Unlikely)
CL Item
Possible (Possibly)
C0332149 (NCI Metathesaurus)
CL Item
Probable (Probably)
C0332148 (NCI Metathesaurus)
CL Item
Definite (Definitely)
CL209464 (NCI Metathesaurus)
LaboratoryProcedureAbsoluteNeutrophilCountGranulocyteOutcomeInd-3
Item
Peripheral Granulocytes count done?
boolean
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12530 (NCI Thesaurus Property-2)
C0018183 (UMLS 2011AA Property-2)
C63321 (NCI Thesaurus Property-3)
C0948762 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Lab,Hematology,GranulocyteCount
Item
Peripheral Granulocytes count (ANC, 1000/mm3 Nadir)
float
Lab,Hematology,GranDate
Item
Peripheral Granulocytes count, Date
date
Platelets
Item
Peripheral Platelet count done?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0005821 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
HematologyPlateletLabUnspecifiedValue
Item
Peripheral Platelet count (mm3 Nadir)
float
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
Lab,Hematology,PlateletDate
Item
Peripheral Platelet count, Date
date
Hemoglobin
Item
Hemoglobin done?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0019046 (UMLS CUI-1)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Hemoglobin
Item
Hemoglobin (G/DL Nadir)
float
C16676 (NCI Thesaurus Property)
C0019046 (UMLS CUI-1)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
Lab,Hematology,HGBDate
Item
Hemoglobin, Date
date
Item Group
Adverse Events - Section 3
CTC Adverse Event Term
Item
CTC Adverse Event Term
text
C41331 (NCI Thesaurus ObjectClass)
C1516728 (UMLS CUI-1)
C25703 (NCI Thesaurus Property)
C2826934 (UMLS CUI-2)
CTC Adverse Event Grade
Item
CTC Adverse Event Grade
float
C41331 (NCI Thesaurus ObjectClass)
C2985911 (UMLS CUI-1)
C25365 (NCI Thesaurus Property)
Item
CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
text
C25664 (NCI Thesaurus ValueDomain)
C1706735 (UMLS CUI-1)
C49704 (NCI Thesaurus ObjectClass)
C25358 (NCI Thesaurus Property)
CL.10
Code List
CTC Adverse Event Attribution Code (* Attribution Codes for Relationship of Event to Treatment: 1 =Unrelated, 2 =Unlikely, 3 =Possibly, 4 =Probably, 5 =Definitely)
CL Item
Unrelated (Unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (Unlikely)
CL Item
Possible (Possibly)
C0332149 (NCI Metathesaurus)
CL Item
Probable (Probably)
C0332148 (NCI Metathesaurus)
CL Item
Definite (Definitely)
CL209464 (NCI Metathesaurus)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Footer Module
ParticipatingGroupIdentifierCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C1257890 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Study Number Participating Group
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Patient Study ID, Participating Group
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Ccrr Module For Common Toxicity Reporting Form, Gog-0209, Form T
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