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ID
9770
Beschrijving
S0100 FOLLOW UP FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB52E43-75AF-43F2-E034-0003BA12F5E7
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- 25-05-12 25-05-12 -
- 22-01-15 22-01-15 - Martin Dugas
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22 januari 2015
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Creative Commons BY-NC 3.0 Legacy
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FOLLOW UP FORM (S0100)
No Instruction available.
- StudyEvent: S0100 FOLLOW UP FORM
Similar models
No Instruction available.
- StudyEvent: S0100 FOLLOW UP FORM
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CL Item
Alive (Alive)
C2584946 (UMLS CUI-1)
CL Item
Dead (Dead)
C0011065 (UMLS CUI-1)
DeathDate/LastContactDate
Item
Date of last contact or death
date
CancerFollow-upStatusInd
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form? (If Yes, )
boolean
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Progression
Item
Has the patient developed a first relapse or progression that has not been previously reported? (If Yes)
boolean
C0242656 (UMLS CUI-1)
DateofRelapseorProgression
Item
Date of Relapse or Progression
text
Site(s)ofRelapseorProgression
Item
Site(s) of Relapse or Progression
text
NewPrimaryCancerInd
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If Yes,)
boolean
NewPrimarySite
Item
New Primary Site
text
Non-ProtocolTherapyInd
Item
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported? (If Yes)
boolean
Non-ProtocolTherapyDate,First
Item
Date of First Non-Protocol Therapy
date
AgentName
Item
Agents
text
LateAdverseEventInd
Item
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade 3) long term toxicity that has not been previously reported? (If Yes,)
boolean
CTCAdverseEventTerm
Item
Toxicities and Grades
text
Comments
Item
Notes
text
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. ID
text