ID

9457

Description

Chemotherapy Form (Form 25/26-CT) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD161F67-0591-4F92-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD161F67-0591-4F92-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 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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Breast Cancer NCT00066703 Treatment - Chemotherapy Form (Form 25/26-CT) - 2167893v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Chemotherapy Form (Form 25/26-CT)
    1. No Instruction available.
Ccrr Module For Chemotherapy Form (form 25/26-ct)
Description

Ccrr Module For Chemotherapy Form (form 25/26-ct)

IBCSG Patient ID
Description

PatientInternationalBreastCancerStudyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C25530
UMLS 2011AA Property-2
C1512890
Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth
Description

Patient Birth Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0421451
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus Property
C25155
Participating Center/Affiliate
Description

ParticipatingCenter/Affiliate

Data type

text

Center Code
Description

CenterCode

Data type

text

Did the patient complete chemotherapy?
Description

Didthepatientcompletechemotherapy?

Data type

text

Reason code, specify (reason treatment ended)
Description

Reasoncode,specify(reasontreatmentended)

Data type

text

adverse event, specify
Description

Adverseevent,specify

Data type

text

medical decision, specify
Description

Medicaldecision,specify

Data type

text

other, specify
Description

OffTreatmentReason,Other

Data type

text

Reasons chemotherapy was delayed or modified
Description

Reasonschemotherapywasdelayedormodified

Data type

text

other toxicity, specify
Description

othertoxicity,specify

Data type

text

reason other than toxicity, specify
Description

reasonotherthantoxicity,specify

Data type

text

Date of first dose of chemotherapy
Description

PriorChemotherapyBeginDate

Data type

date

Date of last dose of chemotherapy
Description

Dateoflastdoseofchemotherapy

Data type

text

Total number of cycles of the regimen of chemotherapy given
Description

TotalCourseNumber

Data type

float

Investigator Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

Date

Data type

text

Agent Name
Description

Agent

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Agent Dose
Description

AgentDoseLevelValue

Data type

text

Alias
NCI Thesaurus Property
C25488
UMLS 2011AA Property
C0178602
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus Property-2
C25554
UMLS 2011AA Property-2
C0441889
Route of Administration
Description

AgentAdminRoute

Data type

text

Schedule & Frequency
Description

Schedule&Frequency

Data type

text

Leukocytes CTCAE Grade
Description

CTCAdverseEventWBCGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Platelets CTCAE Grade
Description

CTCAdverseEventPlateletGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Hemoglobin CTCAE Grade
Description

CTCAdverseEventHemoglobinGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Mucositis/Stomatis CTCAE Grade
Description

CTCAdverseEventStomatitisGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Fatigue CTCAE Grade
Description

CTCAdverseEventFatigueGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Dizziness/lightheadedness CTCAE Grade
Description

CTCAdverseEventDizzinessGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Somnolence/Depressed level of consciousness CTCAE Grade
Description

CTCAdverseEventConsciousnessGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Memory impairment CTCAE Grade
Description

CTCAdverseEventMemoryGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Mood alternation-depression CTCAE Grade
Description

CTCAdverseEventDepressionGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Neuropathy-sensory CTCAE Grade
Description

CommonToxicityCriteriaAdverseEventPeripheralSensoryNeuropathyGrade

Data type

float

Alias
NCI Thesaurus ObjectClass
C49704
UMLS 2011AA ObjectClass
C1516728
NCI Thesaurus ValueDomain
C18000
UMLS 2011AA ValueDomain
C0919553
NCI Metathesaurus Property
C0151313
Did the patient have other Grade 3 or higher adverse event(s)?
Description

DidthepatienthaveotherGrade3orhigheradverseevent(s)?

Data type

boolean

If yes, specify other CTCAE terms not listed
Description

CTCAdverseEventTermSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25703
UMLS 2011AA Property
C1515273
CTCAE Grade
Description

CTC Adverse Event Grade

Data type

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS CUI-1
C2985911
NCI Thesaurus Property
C25365
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Chemotherapy Form (Form 25/26-CT)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Chemotherapy Form (form 25/26-ct)
PatientInternationalBreastCancerStudyGroupIdentifierNumber
Item
IBCSG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25530 (NCI Thesaurus Property-2)
C1512890 (UMLS 2011AA Property-2)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient Birth Date
Item
Patient's Date of Birth
date
C25164 (NCI Thesaurus ValueDomain)
C0421451 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C25155 (NCI Thesaurus Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
CenterCode
Item
Center Code
text
Item
Did the patient complete chemotherapy?
text
CL.1
Code List
Did the patient complete chemotherapy?
CL Item
No, Will Never Start (no, will never start)
CL Item
No, Started But Stopped Early (no, started but stopped early)
CL Item
Yes, Completed With Modifications Or Delays Of One Week Or More (yes, completed with modifications or delays of one week or more)
CL Item
Yes, Completed As Planned (yes, completed as planned)
Item
Reason code, specify (reason treatment ended)
text
CL.2
Code List
Reason code, specify (reason treatment ended)
CL Item
Patient Refused (patient refused)
CL Item
Adverse Event (adverse event)
C41331 (NCI Thesaurus)
C0877248 (UMLS 2011AA)
CL Item
Medical Decision (medical decision)
CL Item
Recurrence (recurrence)
C3352 (NCI Thesaurus)
C0034897 (UMLS 2011AA)
CL Item
Death On Study (death on study)
CL Item
Error (error)
C0743559 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
Adverseevent,specify
Item
adverse event, specify
text
Medicaldecision,specify
Item
medical decision, specify
text
OffTreatmentReason,Other
Item
other, specify
text
Item
Reasons chemotherapy was delayed or modified
text
CL.3
Code List
Reasons chemotherapy was delayed or modified
CL Item
Hematologic Toxicity (hematologic toxicity)
CL Item
Other Toxicity, Specify (other toxicity, specify)
CL Item
Reason Other Than Toxicity, Specify (reason other than toxicity, specify)
othertoxicity,specify
Item
other toxicity, specify
text
reasonotherthantoxicity,specify
Item
reason other than toxicity, specify
text
PriorChemotherapyBeginDate
Item
Date of first dose of chemotherapy
date
Dateoflastdoseofchemotherapy
Item
Date of last dose of chemotherapy
text
TotalCourseNumber
Item
Total number of cycles of the regimen of chemotherapy given
float
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Date
Item
Date
text
Agent
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
AgentDoseLevelValue
Item
Agent Dose
text
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25554 (NCI Thesaurus Property-2)
C0441889 (UMLS 2011AA Property-2)
AgentAdminRoute
Item
Route of Administration
text
Schedule&Frequency
Item
Schedule & Frequency
text
CTCAdverseEventWBCGrade
Item
Leukocytes CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventPlateletGrade
Item
Platelets CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventHemoglobinGrade
Item
Hemoglobin CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventStomatitisGrade
Item
Mucositis/Stomatis CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventFatigueGrade
Item
Fatigue CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventDizzinessGrade
Item
Dizziness/lightheadedness CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventConsciousnessGrade
Item
Somnolence/Depressed level of consciousness CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventMemoryGrade
Item
Memory impairment CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventDepressionGrade
Item
Mood alternation-depression CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CommonToxicityCriteriaAdverseEventPeripheralSensoryNeuropathyGrade
Item
Neuropathy-sensory CTCAE Grade
float
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C0151313 (NCI Metathesaurus Property)
DidthepatienthaveotherGrade3orhigheradverseevent(s)?
Item
Did the patient have other Grade 3 or higher adverse event(s)?
boolean
CTCAdverseEventTermSpecify
Item
If yes, specify other CTCAE terms not listed
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25703 (NCI Thesaurus Property)
C1515273 (UMLS 2011AA Property)
CTC Adverse Event Grade
Item
CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C2985911 (UMLS CUI-1)
C25365 (NCI Thesaurus Property)
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