ID

9764

Description

ECOG Long-Term Follow-up Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC32795E-CBE0-2328-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC32795E-CBE0-2328-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/22/15 1/22/15 - Martin Dugas
Uploaded on

January 22, 2015

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License

Creative Commons BY-NC 3.0 Legacy
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Long-Term Follow-up Form (ECOG E2100)

English

Form No. 1555

1 forms  
  1. StudyEvent: ECOG Long-Term Follow-up Form (E2100)
    1. Form No. 1555
ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Patient's Name
Description

Patient'sName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Are data amended?
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Reporting Period Start Date (M D Y)
Description

IntervalReportFromDate

Data type

date

Reporting Period End Date (M D Y)
Description

IntervalReportToDate

Data type

date

Comments
Description

Comments

Data type

text

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

Vital Status
Description

Vital Status

Alias
UMLS CUI-1
C1148433
Patient's Vital Status
Description

Patient'sVitalStatus

Data type

text

Date of Last Contact or Death (M D Y)
Description

DeathDate/LastContactDate

Data type

date

Primary Cause of Death (if applicable)
Description

DeathReason

Data type

text

Describe cause of death
Description

DeathReason,Specify

Data type

text

Disease Follow-up Status
Description

Disease Follow-up Status

Alias
UMLS CUI-1
C0589120
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
Description

CancerFollow-upStatusInd

Data type

text

Date of last clinical assessment (M D Y)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of Progression
Description

Notice Of Progression

Alias
UMLS CUI-1
C0242656
Has the patient developed a first progression that has not been previously reported?
Description

HASTHEPATIENTDEVELOPEDAFIRSTPROGRESSIONTHATHASNOTBEENPREVIOUSLYREPORTED?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0242656
Date of progression (M D Y)
Description

ProgressionDate

Data type

date

Site(s) of progression
Description

ProgressionSite

Data type

text

Did a physician make a formal diagnosis of progressive disease?
Description

PhysicianProgressiveDiagnosisInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus Property
C25254
UMLS 2011AA Property
C0205329
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
Notice Of New Primary
Description

Notice Of New Primary

Alias
UMLS CUI-1
C0751623
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Description

NewPrimaryCancerInd

Data type

boolean

Site(s) of new primary (If new primary site is AML/MDS, please submit NCI AML/MDS form)
Description

NewPrimarySite

Data type

text

Toxicity
Description

Toxicity

Alias
UMLS CUI-1
C0040539
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3) long term toxicity that has not been previously reported? (NOTE: Do not report toxicities occurring after start of non-protocol therapy.)
Description

Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3)longtermtoxicitythathasnotbeenpreviouslyreported?

Data type

boolean

Alias
UMLS CUI-1
C0040539
Non-protocol Therapy
Description

Non-protocol Therapy

Alias
UMLS CUI-1
C1518384
UMLS CUI-2
C0087111
Has the patient received any non-protocol cancer therapy prior to first progression (not previously reported)?
Description

Hasthepatientreceivedanynon-protocolcancertherapypriortofirstprogression(notpreviouslyreported)?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1518384
UMLS CUI-2
C0087111
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Similar models

Form No. 1555

1 forms
  1. StudyEvent: ECOG Long-Term Follow-up Form (E2100)
    1. Form No. 1555
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain-2)
C1704379 (UMLS 2011AA ValueDomain-2)
Patient'sName
Item
Patient's Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IntervalReportFromDate
Item
Reporting Period Start Date (M D Y)
date
IntervalReportToDate
Item
Reporting Period End Date (M D Y)
date
Comments
Item
Comments
text
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
Item Group
Vital Status
C1148433 (UMLS CUI-1)
Item
Patient's Vital Status
text
CL.2
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of Last Contact or Death (M D Y)
date
Item
Primary Cause of Death (if applicable)
text
CL.3
Code List
Primary Cause of Death (if applicable)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death
text
Item Group
Disease Follow-up Status
C0589120 (UMLS CUI-1)
Item
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
text
CL.4
Code List
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of last clinical assessment (M D Y)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of Progression
C0242656 (UMLS CUI-1)
Item
Has the patient developed a first progression that has not been previously reported?
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0242656 (UMLS CUI-1)
CL.5
Code List
Has the patient developed a first progression that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate
Item
Date of progression (M D Y)
date
ProgressionSite
Item
Site(s) of progression
text
Item
Did a physician make a formal diagnosis of progressive disease?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25254 (NCI Thesaurus Property)
C0205329 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
CL.6
Code List
Did a physician make a formal diagnosis of progressive disease?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Notice Of New Primary
C0751623 (UMLS CUI-1)
NewPrimaryCancerInd
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
boolean
NewPrimarySite
Item
Site(s) of new primary (If new primary site is AML/MDS, please submit NCI AML/MDS form)
text
Item Group
Toxicity
C0040539 (UMLS CUI-1)
Toxicity
Item
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3) long term toxicity that has not been previously reported? (NOTE: Do not report toxicities occurring after start of non-protocol therapy.)
boolean
C0040539 (UMLS CUI-1)
Item Group
Non-protocol Therapy
C1518384 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Non-protocol Therapy
Item
Has the patient received any non-protocol cancer therapy prior to first progression (not previously reported)?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1518384 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
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