ID

9212

Description

Form 5M - Minimal Follow-Up Report Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6FFB989-6864-715F-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6FFB989-6864-715F-E034-0003BA0B1A09

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00049543 Follow-Up - Form 5M - Minimal Follow-Up Report - 2050474v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Form 5M - Minimal Follow-Up Report
    1. No Instruction available.
Patient Information
Description

Patient Information

Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (first - middle - last)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Description

PatientMedicalRecordNumber

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Registered Investigator (NCI Investigator #)
Description

RegisteredInvestigator

Data type

text

Status
Description

Status

Patient's Vital Status
Description

Patient'sVitalStatus

Data type

text

Primary Cause of Death
Description

DeathReason

Data type

text

Describe cause of death
Description

DeathReason,Specify

Data type

text

Date of Last Contact or Death (yyyy mmm dd)
Description

DeathDate/LastContactDate

Data type

date

Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
Description

CancerFollow-upStatusInd

Data type

text

Date of Last Clinical Assessment (yyyy mmm dd)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has the patient developed a first progression (or relapse) that has not been previously reported? (* submit Form 9 Relapse Report if this is the first evidence of recurrence)
Description

ProgressionInd

Data type

boolean

Date of Progression (yyyy mmm dd)
Description

ProgressionDate

Data type

date

Other Malignancies Or Myelodysplastic Syndrome
Description

Other Malignancies Or Myelodysplastic Syndrome

Has a new primary cancer or MDS been diagnosed that was not previously reported?
Description

NewPrimaryCancerInd

Data type

boolean

Date of diagnosis (yyyy mmm dd)
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Malignancy Type
Description

NewPrimaryMalignancyType

Data type

text

Site(s) of New Primary
Description

NewPrimarySite

Data type

text

Describe
Description

NewPrimaryDetail

Data type

text

Ncic Ctg Use Only
Description

Ncic Ctg Use Only

Logged
Description

LoggedEntryInitials

Data type

text

Unnamed (Logged Date)
Description

LoggedEntryDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
RA
Description

RegulatoryAffairsReviewInitials

Data type

text

Unnamed (RA Date)
Description

RegulatoryAffairsReviewDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Study Coord
Description

CoordinatorReviewInitials

Data type

text

Unnamed (Coord Date)
Description

CoordinatorReviewDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Phy
Description

PhysicianReviewInitials

Data type

text

Data Ent'd
Description

DataEntryInitials

Data type

text

Verified
Description

DataVerificationInitials

Data type

text

Header
Description

Header

Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (first - middle - last)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Comments
Description

Comments

COMMENTS
Description

Comments

Data type

text

Investigator Signature
Description

Investigator Signature

Investigator Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Description

FormCompletionDate,Original

Data type

date

Ccrr Module For Form 5m - Minimal Follow-up Report
Description

Ccrr Module For Form 5m - Minimal Follow-up Report

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Form 5M - Minimal Follow-Up Report
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Status
Item
Patient's Vital Status
text
CL.1
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary Cause of Death
text
CL.2
Code List
Primary Cause of Death
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death
text
DeathDate/LastContactDate
Item
Date of Last Contact or Death (yyyy mmm dd)
date
Item
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
text
CL.3
Code List
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (yyyy mmm dd)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
ProgressionInd
Item
Has the patient developed a first progression (or relapse) that has not been previously reported? (* submit Form 9 Relapse Report if this is the first evidence of recurrence)
boolean
ProgressionDate
Item
Date of Progression (yyyy mmm dd)
date
Item Group
Other Malignancies Or Myelodysplastic Syndrome
NewPrimaryCancerInd
Item
Has a new primary cancer or MDS been diagnosed that was not previously reported?
boolean
NewPrimaryCancerDate
Item
Date of diagnosis (yyyy mmm dd)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimaryMalignancyType
Item
Malignancy Type
text
NewPrimarySite
Item
Site(s) of New Primary
text
NewPrimaryDetail
Item
Describe
text
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Unnamed (Logged Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
RegulatoryAffairsReviewInitials
Item
RA
text
RegulatoryAffairsReviewDate
Item
Unnamed (RA Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Unnamed (Coord Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Header
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Form 5m - Minimal Follow-up Report
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