Long-Term Follow-Up for Survival and Disease Status; Patient Withdrawal from Study; Notification of Patient Death; Clarification Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative
C1320722 (UMLS CUI-1)
Site Number
Item
Site Number
text
C2825164 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Patient Number
Item
Patient Number
text
C0030705 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Item Group
Long-Term Follow-Up for Survival and Disease Status
C1517942 (UMLS CUI-1)
C1148433 (UMLS CUI-2)
C0699749 (UMLS CUI-3)
Item
Patient status
integer
C0449437 (UMLS CUI [1])
Patient status
Code List
Patient status
CL Item
Alive (1)
CL Item
Dead (complete "Notification of Patient Death" form) (2)
CL Item
Lost to follow-up (3)
Date last known alive
Item
Date last known alive
date
C0011008 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C0038952 (UMLS CUI [1,3])
Date of last contact
Item
Date of last contact
date
C0805839 (UMLS CUI [1])
Item
How was contact made?
integer
C1705415 (UMLS CUI [1])
How was contact made?
Code List
How was contact made?
CL Item
tumor registry (1)
CL Item
contact with patient (2)
CL Item
contact with MD (3)
CL Item
contact with family (4)
CL Item
other, specify (5)
Specify other contact
Item
Specify other contact
text
C1705415 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Does the patient have an ongoing response to Iodine-131 Anti-B1 Antibody?
Item
Does the patient have an ongoing response to Iodine-131 Anti-B1 Antibody?
boolean
C0768182 (UMLS CUI [1,1])
C0521982 (UMLS CUI [1,2])
C0549178 (UMLS CUI [1,3])
Has additional therapy been given for NHL since Anti-B1?
Item
Has additional therapy been given for NHL since Anti-B1?
boolean
C0024305 (UMLS CUI [1,1])
C1706712 (UMLS CUI [1,2])
C0768182 (UMLS CUI [2])
Has the patient had a documented new diagnosis of myelodysplasia?
Item
Has the patient had a documented new diagnosis of myelodysplasia?
boolean
C0026985 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
If yes, date of diagnosis (myelodysplasia)
Item
If yes, date of diagnosis (myelodysplasia)
date
C0026985 (UMLS CUI [1,1])
C2316983 (UMLS CUI [1,2])
Has the patient had a new diagnosis of another malignancy?
Item
Has the patient had a new diagnosis of another malignancy?
boolean
C0006826 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
If yes, date of diagnosis (another malignancy)
Item
If yes, date of diagnosis (another malignancy)
date
C0006826 (UMLS CUI [1,1])
C2316983 (UMLS CUI [1,2])
Is the patient taking thyroid medication?
Item
Is the patient taking thyroid medication?
boolean
C0040128 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
If Yes, drug name (thyroid medication)
Item
If Yes, drug name (thyroid medication)
text
C0040128 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C2360065 (UMLS CUI [1,3])
Start date (thyroid medication)
Item
Start date (thyroid medication)
date
C0040128 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0808070 (UMLS CUI [1,3])
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
Signature of Investigator
Item
Signature of Investigator
text
C2346576 (UMLS CUI [1])
Signature of Investigator Date
Item
Signature of Investigator Date
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Patient Withdrawal from Study
C0422727 (UMLS CUI-1)
Date of withdrawal from study
Item
Date of withdrawal from study
date
C0422727 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Reason for withdrawal from study
integer
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Reason for withdrawal from study
Code List
Reason for withdrawal from study
CL Item
Patient was lost to follow-up (explain below) (4)
CL Item
Patient wished to withdraw from study (explain below) (5)
CL Item
Patient received alternative therapy (explain below) (7)
CL Item
Patient had progressive disease (9)
CL Item
Patient died (complete "Notification of Patient Death" form) (10)
CL Item
Other (specify) (99)
Specify other reason for withdrawal from study
Item
Specify other reason for withdrawal from study
text
C0422727 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Explanation of withdrawal (when appropriate)
Item
Explanation of withdrawal (when appropriate)
text
C2349954 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
Item Group
Notification of Patient Death
C0422202 (UMLS CUI-1)
C0011065 (UMLS CUI-2)
Date of death
Item
Date of death
date
C1148348 (UMLS CUI [1])
Item
Cause of death
integer
C0007465 (UMLS CUI [1])
Cause of death
Code List
Cause of death
CL Item
Progression of lymphoma (1)
CL Item
Complications related to drug (complete Adverse Experiences form) (2)
CL Item
Other (specify) (3)
Specify other cause of death
Item
Specify other cause of death
text
C0007465 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
If cause of death was related to complications of treatment, please describe or reference forms on which information is recorded
Item
If cause of death was related to complications of treatment, please describe or reference forms on which information is recorded
text
C0007465 (UMLS CUI [1])
C0087111 (UMLS CUI [2,1])
C0009566 (UMLS CUI [2,2])
C0869014 (UMLS CUI [2,3])
C0678257 (UMLS CUI [3])
Item
Relationship of study drug to patient's death
integer
C0304229 (UMLS CUI [1,1])
C0011065 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Relationship of study drug to patient's death
Code List
Relationship of study drug to patient's death
CL Item
None (1)
CL Item
Remote (2)
CL Item
Possible (3)
CL Item
Probable (4)
Item
Source of information concerning death of patient
integer
C0011065 (UMLS CUI [1])
C0683836 (UMLS CUI [2])
Source of information concerning death of patient
Code List
Source of information concerning death of patient
CL Item
Hospital physician (1)
CL Item
Patient's physician (2)
CL Item
Family (3)
CL Item
Newspaper (obituary) (4)
CL Item
Tumor registry (5)
CL Item
Other (specify) (6)
Specify other source of information concerning death of patient
Item
Specify other source of information concerning death of patient
text
C0011065 (UMLS CUI [1])
C0683836 (UMLS CUI [2])
C0205394 (UMLS CUI [3])
C2348235 (UMLS CUI [4])
Item Group
Clarification Form
C2986669 (UMLS CUI-1)
Form Number
Item
Form Number
integer
C1301746 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Series Page Number
Item
Series Page Number
integer
C0205549 (UMLS CUI [1,1])
C1704732 (UMLS CUI [1,2])
C0237753 (UMLS CUI [1,3])
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial