ID

9391

Beskrivning

Form 9 - Relapse/ Progressive Disease Report Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A06B0201-DAB9-5179-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A06B0201-DAB9-5179-E034-080020C9C0E0

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2014-12-22 2014-12-22 - Martin Dugas
  3. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00049543 Response - Form 9 - Relapse/ Progressive Disease Report - 2034459v3.0

Tysk Engelsk

Form 9 - Relapse/ Progressive Disease Report

1 Formulär  
  1. StudyEvent: Form 9 - Relapse/ Progressive Disease Report
    1. Form 9 - Relapse/ Progressive Disease Report
1. PATIENT INFORMATION
Beskrivning

1. PATIENT INFORMATION

PatientStudyID,CoordinatingGroup
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

PatientMedicalRecordNumber
Beskrivning

PatientMedicalRecordNumber

Datatyp

text

Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
UMLS CUI-1
C2986440
PatientStudyID,ParticipatingGroup
Beskrivning

PatientStudyID,ParticipatingGroup

Datatyp

text

NCIInstitutionNumber
Beskrivning

NCIInstitutionNumber

Datatyp

text

PatientSocialSecurityNumber
Beskrivning

PatientSocialSecurityNumber

Datatyp

float

InstitutionName
Beskrivning

InstitutionName

Datatyp

text

RegisteredInvestigator
Beskrivning

RegisteredInvestigator

Datatyp

text

VisitReportMonthSpecify
Beskrivning

VisitReportMonthSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C29846
UMLS 2011AA Property
C0439231
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Radiologie
Beskrivning

Radiologie

Alias
UMLS CUI-1
C1299496
Röntgen Thorax
Beskrivning

Röntgen Thorax

Datatyp

integer

Alias
UMLS CUI-1
C0039985
CT/MR/Ultraschall oberes Abdomen
Beskrivning

CT/MR/Ultraschall oberes Abdomen

Datatyp

integer

Art der Untersuchung
Beskrivning

Art der Untersuchung

Datatyp

integer

Alias
UMLS CUI-1
C2598109
Knochen Scan
Beskrivning

Knochen Scan

Datatyp

integer

Alias
UMLS CUI-1
C0203668
CT Kopf
Beskrivning

CT Kopf

Datatyp

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C17204
NCI Thesaurus ObjectClass-2
C12419
NCI Thesaurus Property
C20200
UMLS CUI-1
C0412585
Andere radiologische Untersuchung
Beskrivning

Andere radiologische Untersuchung

Datatyp

integer

Art der Untersuchung
Beskrivning

Art der Untersuchung

Datatyp

text

Alias
UMLS CUI-1
C2598109
Untersuchungsdatum
Beskrivning

Untersuchungsdatum

Datatyp

date

Alias
UMLS CUI-1
C2985720
3. DISEASE STATUS
Beskrivning

3. DISEASE STATUS

ProgressionDate
Beskrivning

ProgressionDate

Datatyp

date

TreatmentAssignmentCode
Beskrivning

TreatmentAssignmentCode

Datatyp

text

NCIC CTG use only
Beskrivning

NCIC CTG use only

LoggedEntryInitials
Beskrivning

LoggedEntryInitials

Datatyp

text

LoggedEntryDate
Beskrivning

LoggedEntryDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
CoordinatorReviewInitials
Beskrivning

CoordinatorReviewInitials

Datatyp

text

CoordinatorReviewDate
Beskrivning

CoordinatorReviewDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
PhysicianReviewInitials
Beskrivning

PhysicianReviewInitials

Datatyp

text

DataEntryInitials
Beskrivning

DataEntryInitials

Datatyp

text

DataVerificationInitials
Beskrivning

DataVerificationInitials

Datatyp

text

4. RECURRENCE TABLE
Beskrivning

4. RECURRENCE TABLE

Lung (* Local recurrence in the area of tumour bed or Hilum.)
Beskrivning

LungSiteInd

Datatyp

boolean

Liver
Beskrivning

LiverSiteInd

Datatyp

boolean

Pleura (to be discussed)
Beskrivning

PleuraSiteInd

Datatyp

boolean

CNS (excluding brain)
Beskrivning

CNSSiteInd

Datatyp

boolean

Brain
Beskrivning

BrainSiteInd

Datatyp

boolean

Bone
Beskrivning

BoneSiteInd

Datatyp

boolean

Opposite Lung
Beskrivning

OppositeLungInd

Datatyp

boolean

Regional Lymph nodes (** Mediastinal lymph nodes)
Beskrivning

RegionalLymphNode(s)Ind

Datatyp

boolean

Distant Lymph Nodes (*** Spread of disease beyond limits specified as same lung or regional lymph)
Beskrivning

DistantLymphNode(s)Ind

Datatyp

boolean

Distant Skin or Subcutaneous tissue
Beskrivning

DistantSkin/SubcutaneousTissueInd

Datatyp

boolean

Distant Lung Site Ind
Beskrivning

DistantLungSiteInd

Datatyp

boolean

Ascites
Beskrivning

AscitesInd

Datatyp

boolean

Pleural Effusion
Beskrivning

PleuralEffusionInd

Datatyp

boolean

Local Lung Site Ind
Beskrivning

LocalLungSiteIndicator

Datatyp

boolean

Other
Beskrivning

OtherSiteInd

Datatyp

boolean

OtherSiteName
Beskrivning

OtherSiteName

Datatyp

text

ProgressionSuspectedBeginDate
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

ProgressionDefiniteBeginDate
Beskrivning

ProgressionDefiniteBeginDate

Datatyp

date

ProgressionCriteria
Beskrivning

ProgressionCriteria

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus Property
C25466
UMLS 2011AA Property
C0243161
5. TREATMENT PLAN
Beskrivning

5. TREATMENT PLAN

6. COMMENTS
Beskrivning

6. COMMENTS

Have You attached copies of
Beskrivning

Attached copies

Datatyp

integer

8. INVESTIGATOR SIGNATURE
Beskrivning

8. INVESTIGATOR SIGNATURE

PersonCompletingForm,FirstName
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
InvestigatorSignature
Beskrivning

InvestigatorSignature

Datatyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
PersonCompletingForm,LastName
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

FormCompletionDate,Original
Beskrivning

FormCompletionDate,Original

Datatyp

date

Tillbaka till toppen

Similar models

Form 9 - Relapse/ Progressive Disease Report

1 Formulär
  1. StudyEvent: Form 9 - Relapse/ Progressive Disease Report
    1. Form 9 - Relapse/ Progressive Disease Report
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
PatientStudyID,CoordinatingGroup
Item
text
PatientMedicalRecordNumber
Item
text
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
PatientStudyID,ParticipatingGroup
Item
text
NCIInstitutionNumber
Item
text
PatientSocialSecurityNumber
Item
float
InstitutionName
Item
text
RegisteredInvestigator
Item
text
VisitReportMonthSpecify
Item
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C29846 (NCI Thesaurus Property)
C0439231 (UMLS 2011AA Property)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
Item Group
Radiologie
C1299496 (UMLS CUI-1)
Item
Röntgen Thorax
integer
C0039985 (UMLS CUI-1)
CL.1
Code List
Röntgen Thorax
CL Item
Nicht durchgeführt (0)
CL Item
Negativ (1)
CL Item
Auffällig, nicht maligne (2)
CL Item
Positiv (3)
Item
CT/MR/Ultraschall oberes Abdomen
integer
CL.2
Code List
CT/MR/Ultraschall oberes Abdomen
CL Item
Nicht durchgeführt (0)
CL Item
Negativ (1)
CL Item
Auffällig, nicht maligne (2)
CL Item
Positiv (3)
Item
Art der Untersuchung
integer
C2598109 (UMLS CUI-1)
CL.3
Code List
Art der Untersuchung
CL Item
Ultraschall (1)
CL Item
CT (2)
CL Item
MR (3)
Item
Knochen Scan
integer
C0203668 (UMLS CUI-1)
CL.4
Code List
Knochen Scan
CL Item
Nicht durchgeführt (0)
CL Item
Negativ (1)
CL Item
Auffällig, nicht maligne (2)
CL Item
Positiv (3)
Item
CT Kopf
integer
C25284 (NCI Thesaurus ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C12419 (NCI Thesaurus ObjectClass-2)
C20200 (NCI Thesaurus Property)
C0412585 (UMLS CUI-1)
CL.5
Code List
CT Kopf
CL Item
CT Kopf nicht durchgeführt (0)
CL Item
CT Kopf negativ (1)
CL Item
CT Kopf auffällig, nicht maligne (2)
CL Item
CT Kopf positiv (3)
Item
Andere radiologische Untersuchung
integer
CL.6
Code List
Andere radiologische Untersuchung
CL Item
Nicht durchgeführt (0)
CL Item
Negativ (1)
CL Item
Auffällig, nicht maligne (2)
CL Item
Positiv (3)
Assessment Type
Item
Art der Untersuchung
text
C2598109 (UMLS CUI-1)
Assessment date
Item
Untersuchungsdatum
date
C2985720 (UMLS CUI-1)
ProgressionDate
Item
date
TreatmentAssignmentCode
Item
text
LoggedEntryInitials
Item
text
LoggedEntryDate
Item
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
text
CoordinatorReviewDate
Item
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
text
DataEntryInitials
Item
text
DataVerificationInitials
Item
text
LungSiteInd
Item
Lung (* Local recurrence in the area of tumour bed or Hilum.)
boolean
LiverSiteInd
Item
Liver
boolean
PleuraSiteInd
Item
Pleura (to be discussed)
boolean
CNSSiteInd
Item
CNS (excluding brain)
boolean
BrainSiteInd
Item
Brain
boolean
BoneSiteInd
Item
Bone
boolean
OppositeLungInd
Item
Opposite Lung
boolean
RegionalLymphNode(s)Ind
Item
Regional Lymph nodes (** Mediastinal lymph nodes)
boolean
DistantLymphNode(s)Ind
Item
Distant Lymph Nodes (*** Spread of disease beyond limits specified as same lung or regional lymph)
boolean
DistantSkin/SubcutaneousTissueInd
Item
Distant Skin or Subcutaneous tissue
boolean
DistantLungSiteInd
Item
Distant Lung Site Ind
boolean
AscitesInd
Item
Ascites
boolean
PleuralEffusionInd
Item
Pleural Effusion
boolean
LocalLungSiteIndicator
Item
Local Lung Site Ind
boolean
OtherSiteInd
Item
Other
boolean
OtherSiteName
Item
text
ProgressionSuspectedBeginDate
Item
date
ProgressionDefiniteBeginDate
Item
date
ProgressionCriteria
Item
text
C25331 (NCI Thesaurus ObjectClass)
C25466 (NCI Thesaurus Property)
C0243161 (UMLS 2011AA Property)
Item Group
Item
Have You attached copies of
integer
CL.18
Code List
Have You attached copies of
CL Item
chest x-ray (1)
CL Item
CT of abdomen/pelvis (2)
CL Item
pathology/cytology report(s) (3)
CL Item
other radiology (4)
CL Item
MRI (5)
CL Item
Other: specify (6)
PersonCompletingForm,FirstName
Item
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InvestigatorSignature
Item
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
text
FormCompletionDate,Original
Item
date
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