ID

9358

Description

SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT FORM FOR FIRST CYCLE (S0227) S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C3C405-9249-3D84-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C3C405-9249-3D84-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  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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Cervical Cancer NCT00057928 Treatment - SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT FORM FOR FIRST CYCLE (S0227) - 2057464v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT FORM FOR FIRST CYCLE (S0227)
    1. No Instruction available.
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 / Affiliate
Description

InstitutionName

Data type

text

Physician (Groups other than SWOG)
Description

RegisteredInvestigator

Data type

text

Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

Particip.GroupProtocolNumber

Data type

float

Pt. ID
Description

PatientStudyID,ParticipatingGroup

Data type

text

Status
Description

Status

Date of Last Contact or Death
Description

DeathDate/LastContactDate

Data type

date

Vital Status
Description

Patient'sVitalStatus

Data type

text

First Cycle Of Treatment
Description

First Cycle Of Treatment

Cycle start date (same as treatment start date)
Description

Chemotherapy Cycle Start Date

Data type

date

Alias
UMLS CUI-1
C1302181
UMLS CUI-2
C3173309
Cycle end date (Date immediately prior to the date next cycle begins, or date decision made to discontinue patient from protocol treatment if last cycle.)
Description

Chemotherapy Cycle End Date

Data type

text

Alias
UMLS CUI-1
C1302181
UMLS CUI-2
C0806020
Weight first day this cycle (kg)
Description

PatientWeight

Data type

float

BSA first day this cycle
Description

BodySurfaceArea

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Were there any dose modifications or additions/omissions to protocol treatment
Description

DoseModification(Change)

Data type

text

Total dose of gemcitabine for this cycle (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

float

Total dose of gemcitabine for this cycle (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

float

Total dose of gemcitabine for this cycle (Arm 2 only)
Description

AgentTotalDose(percourse)

Data type

float

Concomitant Medications / Medical Interventions
Description

Concomitant Medications / Medical Interventions

Start Date
Description

AgentBeginDate

Data type

date

Stop Date
Description

AgentEndDate

Data type

date

Others, specify
Description

AgentName

Data type

text

Others, specify
Description

AgentName

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group S0227 Treatment Form For First Cycle (s0227)
Description

Ccrr Module For Southwest Oncology Group S0227 Treatment Form For First Cycle (s0227)

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No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 TREATMENT FORM FOR FIRST CYCLE (S0227)
    1. No Instruction available.
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 / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
float
PatientStudyID,ParticipatingGroup
Item
Pt. ID
text
Item Group
Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death
date
Item
Vital Status
text
CL.1
Code List
Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
First Cycle Of Treatment
Chemotherapy Cycle Start Date
Item
Cycle start date (same as treatment start date)
date
C1302181 (UMLS CUI-1)
C3173309 (UMLS CUI-2)
Chemotherapy Cycle End Date
Item
Cycle end date (Date immediately prior to the date next cycle begins, or date decision made to discontinue patient from protocol treatment if last cycle.)
text
C1302181 (UMLS CUI-1)
C0806020 (UMLS CUI-2)
PatientWeight
Item
Weight first day this cycle (kg)
float
BodySurfaceArea
Item
BSA first day this cycle
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item
Were there any dose modifications or additions/omissions to protocol treatment
text
CL.2
Code List
Were there any dose modifications or additions/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, specify in comments)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned, specify in comments)
AgentTotalDose(percourse)
Item
Total dose of gemcitabine for this cycle (Arm 2 only)
float
AgentTotalDose(percourse)
Item
Total dose of gemcitabine for this cycle (Arm 2 only)
float
AgentTotalDose(percourse)
Item
Total dose of gemcitabine for this cycle (Arm 2 only)
float
Item Group
Concomitant Medications / Medical Interventions
AgentBeginDate
Item
Start Date
date
AgentEndDate
Item
Stop Date
date
AgentName
Item
Others, specify
text
AgentName
Item
Others, specify
text
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group S0227 Treatment Form For First Cycle (s0227)
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