ID

9289

Description

S0205 CETUXIMAB SKIN TOXICITIES 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=A66332D9-9FC0-48D9-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A66332D9-9FC0-48D9-E034-0003BA0B1A09

Keywords

Versions (2)
  1. 9/20/12 9/20/12 -
  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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Pancreatic Cancer NCT00075686 Toxicity - S0205 CETUXIMAB SKIN TOXICITIES FORM - 2049859v3.0

English

Instructions: Please complete if skin toxicities (Rash/desquamation, Pruritus, Erythema multiforme, Dry skin) are noted on the S0205 Toxicity and Dosage Form.

1 forms  
Header
Description

Header

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

Patient Initials

Data type

text

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

InstitutionName

Data type

text

Affiliate
Description

AffiliateName

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Cetuximab Skin Toxicities
Description

Cetuximab Skin Toxicities

For Stat Center Use
Description

ForStatCenterUse

Data type

text

Toxicity
Description

CTCAdverseEventTerm

Data type

text

Other, specify
Description

CTCAdverseEventTerm,Other

Data type

text

Grade (0-5)
Description

CTCAdverseEventGrade

Data type

text

Cetuximab Action Required (*1-3)
Description

CetuximabActionRequired

Data type

text

Onset
Description

CTCAdverseEventReportBeginDate

Data type

date

Resolved
Description

CTCAdverseEventReportEndDate

Data type

date

If ongoing, check box
Description

Ifongoing,checkbox

Data type

text

Concurrent Therapy/procedures For Cetuximab Skin Toxicities
Description

Concurrent Therapy/procedures For Cetuximab Skin Toxicities

Check box if there are none
Description

Checkboxiftherearenone

Data type

text

Drug/Procedure
Description

Drug/Procedure

Data type

text

Started
Description

TreatmentStartDate

Data type

date

Completed
Description

Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
If ongoing, check box
Description

Ifongoing,checkbox

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Ccrr Module For S0205 Cetuximab Skin Toxicities Form
Description

Ccrr Module For S0205 Cetuximab Skin Toxicities Form

Ccrr Module For S0205 Cetuximab Skin Toxicities Form
Description

Ccrr Module For S0205 Cetuximab Skin Toxicities Form

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Similar models

Instructions: Please complete if skin toxicities (Rash/desquamation, Pruritus, Erythema multiforme, Dry skin) are noted on the S0205 Toxicity and Dosage Form.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
text
Item Group
Cetuximab Skin Toxicities
Item
For Stat Center Use
text
CL.1
Code List
For Stat Center Use
CL Item
Sk11 (SK11)
CL Item
Sk16 (SK16)
CL Item
Sk20 (SK20)
CL Item
Sk80 (SK80)
Item
Toxicity
text
CL.2
Code List
Toxicity
CL Item
Rash/desquamation (Rash/desquamation)
CL Item
Pruritus (Pruritus)
CL Item
Erythema multiforme (Erythema multiforme)
CL Item
Dry skin (Dry skin)
CL Item
Other, specify (Other, specify)
CTCAdverseEventTerm,Other
Item
Other, specify
text
Item
Grade (0-5)
text
CL.3
Code List
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
Cetuximab Action Required (*1-3)
text
CL.4
Code List
Cetuximab Action Required (*1-3)
CL Item
Dose Held (dose held)
CL Item
Dose Reduced (dose reduced)
C49505 (NCI Thesaurus)
C1707814 (UMLS 2011AA)
CL Item
Dose Discontinued (dose discontinued)
CTCAdverseEventReportBeginDate
Item
Onset
date
CTCAdverseEventReportEndDate
Item
Resolved
date
Ifongoing,checkbox
Item
If ongoing, check box
text
Item Group
Concurrent Therapy/procedures For Cetuximab Skin Toxicities
Checkboxiftherearenone
Item
Check box if there are none
text
Drug/Procedure
Item
Drug/Procedure
text
TreatmentStartDate
Item
Started
date
Completed
Item
Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Ifongoing,checkbox
Item
If ongoing, check box
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Cetuximab Skin Toxicities Form
Item Group
Ccrr Module For S0205 Cetuximab Skin Toxicities Form
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