ID

9235

Descrição

S0201 Melacine Arm Cycle-Specific Toxicity and Dosage Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93417EC-7384-694A-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A93417EC-7384-694A-E034-0003BA12F5E7

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 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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Melanoma (Skin) null Toxicity - S0201 Melacine Arm Cycle-Specific Toxicity and Dosage Form - 2055710v3.0

Inglês

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

1 Formulários  
Header
Descrição

Header

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient Initials (L, F M)
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Cycle Number
Descrição

Cycle Number Chemotherapeutics

Tipo de dados

float

Alias
UMLS CUI-1
C2045829
If cycle #1, then Indicate week number for this submission
Descrição

Ifcycle#1,thenIndicateweeknumberforthissubmission

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Physician
Descrição

TreatingPhysician

Tipo de dados

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
Descrição

ParticipatingGroupName

Tipo de dados

text

Study No.
Descrição

StudyNo.

Tipo de dados

text

Pt. ID
Descrição

Pt.ID

Tipo de dados

text

Disease Status
Descrição

Disease Status

Date of Last Contact or Death
Descrição

DeathDate/LastContactDate

Tipo de dados

date

Vital Status
Descrição

Patient'sVitalStatus

Tipo de dados

text

Treatment Status
Descrição

Treatment Status

Is patient still on protocol treatment?
Descrição

Ispatientstillonprotocoltreatment?

Tipo de dados

boolean

Were there any additions, adjustments or omissions to protocol treatment?
Descrição

DoseModification(Change)

Tipo de dados

text

If yes, specify amount and reason
Descrição

DoseModificationReason

Tipo de dados

text

Number of Melacine injections
Descrição

NumberofMelacineinjections

Tipo de dados

text

First date of treatment during this cycle
Descrição

TreatmentFirstDoseBeginDate

Tipo de dados

date

Last date of treatment during this cycle
Descrição

TreatmentLastDoseEndDate

Tipo de dados

date

Toxicity
Descrição

Toxicity

Were toxicities assessed during this time period?
Descrição

Weretoxicitiesassessedduringthistimeperiod?

Tipo de dados

boolean

Date of most recent toxicity assessment
Descrição

SymptomAssessmentDate

Tipo de dados

date

Unnamed3
Descrição

Unnamed3

Tipo de dados

text

Code
Descrição

CTCCode

Tipo de dados

text

Toxicity
Descrição

CTCAdverseEventTerm

Tipo de dados

text

CTC 2.0 Grade (0-5)
Descrição

CTCAdverseEventGrade

Tipo de dados

text

Treatment Relation
Descrição

CTCAdverseEventAttributionCode

Tipo de dados

text

Other Toxicities (specify)
Descrição

CTCAdverseEventTerm,Other

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

Ccrr Module For S0201 Melacine Arm Cycle-specific Toxicity And Dosage Form
Descrição

Ccrr Module For S0201 Melacine Arm Cycle-specific Toxicity And Dosage Form

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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

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
Cycle Number Chemotherapeutics
Item
Cycle Number
float
C2045829 (UMLS CUI-1)
Item
If cycle #1, then Indicate week number for this submission
text
CL.1
Code List
If cycle #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
CL.2
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Treatment Status
Ispatientstillonprotocoltreatment?
Item
Is patient still on protocol treatment?
boolean
Item
Were there any additions, adjustments or omissions to protocol treatment?
text
CL.4
Code List
Were there any additions, adjustments or omissions to protocol treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned (per protocol guidelines))
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned (not per protocol guidelines))
DoseModificationReason
Item
If yes, specify amount and reason
text
NumberofMelacineinjections
Item
Number of Melacine injections
text
TreatmentFirstDoseBeginDate
Item
First date of treatment during this cycle
date
TreatmentLastDoseEndDate
Item
Last date of treatment during this cycle
date
Item Group
Toxicity
Weretoxicitiesassessedduringthistimeperiod?
Item
Were toxicities assessed during this time period?
boolean
SymptomAssessmentDate
Item
Date of most recent toxicity assessment
date
Item
Unnamed3
text
CL.6
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
Toxicity
text
Item
CTC 2.0 Grade (0-5)
text
CL.7
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)
Item
Treatment Relation
text
CL.8
Code List
Treatment Relation
CL Item
Unrelated (unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely)
CL Item
Possibly (possible)
CL Item
Probably (probable)
CL Item
Definitely (definite)
CTCAdverseEventTerm,Other
Item
Other Toxicities (specify)
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0201 Melacine Arm Cycle-specific Toxicity And Dosage Form
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