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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

  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

    No Instruction available.

    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

    Similar models

    No Instruction available.

    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
    Code List
    Patient's Vital Status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    Item
    Primary Cause of Death
    text
    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
    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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