ID

9268

Beschrijving

S0205 Follow Up Form S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11B693E-8E8F-02FA-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11B693E-8E8F-02FA-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
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9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00075686 Follow-Up - S0205 Follow Up Form - 2035701v3.0

Engels

Instructions: Please submit at each follow up after completion of treatment until recurrence, at time of recurrence, and at protocol specified intervals after recurrence. All dates are MONTH, DAY, YEAR. Answer all questions and explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren  
Header
Beschrijving

Header

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution
Beschrijving

InstitutionName

Datatype

text

Affiliate
Beschrijving

AffiliateName

Datatype

text

Physician (Groups other than SWOG)
Beschrijving

RegisteredInvestigator

Datatype

text

Group Name
Beschrijving

GroupName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Beschrijving

StudyNo.

Datatype

text

Pt. ID (VITAL STATUS)
Beschrijving

Pt.ID

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Vital Status
Beschrijving

Patient'sVitalStatus

Datatype

text

Date of last contact or death (DISEASE FOLLOW UP STATUS)
Beschrijving

DeathDate/LastContactDate

Datatype

date

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Beschrijving

CancerFollow-upStatusInd

Datatype

boolean

If Yes, Date of Last Clinical Assessment (NOTICE OF FIRST RELAPSE OR PROGRESSION)
Beschrijving

CancerFollow-upStatusDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has the patient developed a first relapse or progression that has not been previously reported
Beschrijving

DiseaseRelapseProgressionInd-3

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C38155
UMLS 2011AA Property
C0277556
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
NCI Thesaurus Property-3
C19987
UMLS 2011AA Property-3
C0242656
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
If Yes, Date of Relapse or Progression
Beschrijving

ProgressionDate

Datatype

date

Site(s) of Relapse or Progression (NOTICE OF NEW PRIMARY)
Beschrijving

ProgressionSite

Datatype

text

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Beschrijving

NewPrimaryCancerInd

Datatype

boolean

If Yes, Date of Diagnosis
Beschrijving

NewPrimaryCancerDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site (FURTHER TREATMENT)
Beschrijving

NewPrimarySite

Datatype

text

Has the patient received further (non-protocol) treatment for this cancer?
Beschrijving

Non-ProtocolTherapyInd

Datatype

boolean

Specify Regimen (Note: If multiple regimens were received, please specify only the first regiment received after going off protocol treatment.)
Beschrijving

Non-ProtocolTherapyType

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass-2
C2167
UMLS 2011AA ObjectClass-2
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For S0205 Follow Up Form
Beschrijving

Ccrr Module For S0205 Follow Up Form

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Similar models

Instructions: Please submit at each follow up after completion of treatment until recurrence, at time of recurrence, and at protocol specified intervals after recurrence. All dates are MONTH, DAY, YEAR. Answer all questions and explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
InstitutionName
Item
Institution
text
AffiliateName
Item
Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID (VITAL STATUS)
text
Item Group
Unnamed2
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of last contact or death (DISEASE FOLLOW UP STATUS)
date
CancerFollow-upStatusInd
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
boolean
CancerFollow-upStatusDate
Item
If Yes, Date of Last Clinical Assessment (NOTICE OF FIRST RELAPSE OR PROGRESSION)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
DiseaseRelapseProgressionInd-3
Item
Has the patient developed a first relapse or progression that has not been previously reported
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C38155 (NCI Thesaurus Property)
C0277556 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C19987 (NCI Thesaurus Property-3)
C0242656 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
ProgressionDate
Item
If Yes, Date of Relapse or Progression
date
ProgressionSite
Item
Site(s) of Relapse or Progression (NOTICE OF NEW PRIMARY)
text
NewPrimaryCancerInd
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
boolean
NewPrimaryCancerDate
Item
If Yes, Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site (FURTHER TREATMENT)
text
Non-ProtocolTherapyInd
Item
Has the patient received further (non-protocol) treatment for this cancer?
boolean
Non-ProtocolTherapyType
Item
Specify Regimen (Note: If multiple regimens were received, please specify only the first regiment received after going off protocol treatment.)
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass-2)
C1443775 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Follow Up Form
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