ID

9229

Descrizione

S0201 Observation Arm Assessment Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93268F8-DF07-6139-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93268F8-DF07-6139-E034-0003BA12F5E7

Keywords

  1. 19/09/12 19/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy

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Melanoma (Skin) null Toxicity - S0201 Observation Arm Assessment Form - 2055704v3.0

Instructions: Complete at the end of weeks 12, 27, 54, 81. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in a Comments section. Place an X in appropriate boxes. Circle AMENDED items

Header
Descrizione

Header

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient Initials (L, F M)
Descrizione

Patient Initials

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Reporting interval number
Descrizione

Reportingintervalnumber

Tipo di dati

text

If reporting interval #1, then Indicate week number for this submission
Descrizione

Ifreportinginterval#1,thenIndicateweeknumberforthissubmission

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Physician
Descrizione

TreatingPhysician

Tipo di dati

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
Group Name
Descrizione

ParticipatingGroupName

Tipo di dati

text

Study No.
Descrizione

StudyNo.

Tipo di dati

text

Pt. ID
Descrizione

Pt.ID

Tipo di dati

text

Disease Status
Descrizione

Disease Status

Date of Last Contact or Death
Descrizione

DeathDate/LastContactDate

Tipo di dati

date

Vital Status
Descrizione

Patient'sVitalStatus

Tipo di dati

text

Reporting interval start date
Descrizione

IntervalReportFromDate

Tipo di dati

date

Reporting interval end date
Descrizione

IntervalReportToDate

Tipo di dati

date

Adverse Events
Descrizione

Adverse Events

Were adverse events assessed during this time period?
Descrizione

Weretoxicitiesassessedforthisreportinginterval?

Tipo di dati

boolean

Date of most recent toxicity assessment
Descrizione

SymptomAssessmentDate

Tipo di dati

date

Unnamed3
Descrizione

Unnamed3

Tipo di dati

text

Code
Descrizione

CTCCode

Tipo di dati

text

Adverse Event
Descrizione

CTCAdverseEventTerm

Tipo di dati

text

CTC 2.0 Grade (0-5)
Descrizione

CTCAdverseEventGrade

Tipo di dati

text

Other Toxicities (specify)
Descrizione

CTCAdverseEventTerm,Other

Tipo di dati

text

Comments
Descrizione

Comments

Comments
Descrizione

Comments

Tipo di dati

text

Ccrr Module For S0201 Observation Arm Assessment Form
Descrizione

Ccrr Module For S0201 Observation Arm Assessment Form

Similar models

Instructions: Complete at the end of weeks 12, 27, 54, 81. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in a Comments section. Place an X in appropriate boxes. Circle AMENDED items

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Reportingintervalnumber
Item
Reporting interval number
text
Item
If reporting interval #1, then Indicate week number for this submission
text
Code List
If reporting interval #1, then Indicate week number for this submission
CL Item
Week 12 (Week 12)
CL Item
Week 27 (week 27)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
ParticipatingGroupName
Item
Group Name
text
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text
Item Group
Disease Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death
date
Item
Vital Status
text
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
IntervalReportFromDate
Item
Reporting interval start date
date
IntervalReportToDate
Item
Reporting interval end date
date
Item Group
Adverse Events
Weretoxicitiesassessedforthisreportinginterval?
Item
Were adverse events assessed during this time period?
boolean
SymptomAssessmentDate
Item
Date of most recent toxicity assessment
date
Item
Unnamed3
text
Code List
Unnamed3
CL Item
Mark Box If Toxicities Were Assessed But None Were Seen. (Mark box if toxicities were assessed but none were seen.)
CTCCode
Item
Code
text
CTCAdverseEventTerm
Item
Adverse Event
text
Item
CTC 2.0 Grade (0-5)
text
Code List
CTC 2.0 Grade (0-5)
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CTCAdverseEventTerm,Other
Item
Other Toxicities (specify)
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0201 Observation Arm Assessment Form

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