ID

10273

Beschrijving

CALGB: HER-2/NEU Status Form Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D12AD-990B-4739-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D12AD-990B-4739-E034-0003BA0B1A09

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 22-05-15 22-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

22 mei 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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CALGB: HER-2/NEU Status Form

Engels

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. Do not leave any entries blank. Enter -1 to indicate that an answer in unknown, unobtainable, not applicable, or not done. Retain a copy for your records and submit ORIGINAL to the CALGB Data Management Center.

1 Formulieren  
CALGB Information
Beschrijving

CALGB Information

CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBStudyNo

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Amended data?
Beschrijving

AmendedDataInd

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient clinical trial data
Beschrijving

Patient clinical trial data

Patient's Name
Beschrijving

Patient'sName

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschrijving

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

AffiliateName

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Sample Data
Beschrijving

Sample Data

Could the tissue sample be evaluated?
Beschrijving

SpecimenCondition

Datatype

text

If no, specify reason (sample could not be evaluated)
Beschrijving

Ifno,specifyreason(samplecouldnotbeevaluated)

Datatype

text

Testing Data
Beschrijving

Testing Data

Tumor site tested
Beschrijving

Tumorsitetested

Datatype

text

Staining antibody used for IHC
Beschrijving

StainingAntibody

Datatype

text

Other, specify (staining antibody)
Beschrijving

StainingAntibody,Other

Datatype

text

Serum ECD test
Beschrijving

SerumECDtest

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other, specify (serum ECD test)
Beschrijving

Other,specify(serumECDtest)

Datatype

text

Method of testing
Beschrijving

TumorMarkerTestMethod

Datatype

text

Kit used for FISH
Beschrijving

FISHKitorTestType

Datatype

text

Other, specify (FISH Kit)
Beschrijving

FISHKitorTestType,Other

Datatype

double

Testing Results
Beschrijving

Testing Results

Her-2/neu Status
Beschrijving

HER2/neuFinalDiagnosis

Datatype

text

IHC Lab value
Beschrijving

HerceptestScore

Datatype

text

Completed by
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Beschrijving

FormCompletionDate,Original

Datatype

date

Ccrr Module For Calgb: Her-2/neu Status Form
Beschrijving

Ccrr Module For Calgb: Her-2/neu Status Form

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Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. Do not leave any entries blank. Enter -1 to indicate that an answer in unknown, unobtainable, not applicable, or not done. Retain a copy for your records and submit ORIGINAL to the CALGB Data Management Center.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
CALGB Information
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Patient clinical trial data
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
AffiliateName
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
Item Group
Sample Data
Item
Could the tissue sample be evaluated?
text
CL.2
Code List
Could the tissue sample be evaluated?
CL Item
Damaged Or Unusable (no)
CL Item
Useable (yes)
Ifno,specifyreason(samplecouldnotbeevaluated)
Item
If no, specify reason (sample could not be evaluated)
text
Item Group
Testing Data
Item
Tumor site tested
text
CL.3
Code List
Tumor site tested
CL Item
Primary (primary)
C25251 (NCI Thesaurus)
C0205225 (UMLS 2011AA)
CL Item
Metastatic (metastatic)
C14174 (NCI Thesaurus)
C0036525 (UMLS 2011AA)
Item
Staining antibody used for IHC
text
CL.4
Code List
Staining antibody used for IHC
CL Item
Cb-11/ventana Kit (CB11)
CL Item
Dako Herceptest [tm] (DAKO A0485 [Herceptest])
CL Item
Other, Specify (Other, specify)
StainingAntibody,Other
Item
Other, specify (staining antibody)
text
Item
Serum ECD test
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.5
Code List
Serum ECD test
CL Item
Other, Specify (Other, specify)
Other,specify(serumECDtest)
Item
Other, specify (serum ECD test)
text
Item
Method of testing
text
CL.6
Code List
Method of testing
CL Item
Immunohistochemistry (ihc) (Immunohistochemistry (IHC))
CL Item
Fluorescence In Situ Hybridization (fish) (Fluorescent in-situ hybridization (FISH))
Item
Kit used for FISH
text
CL.7
Code List
Kit used for FISH
CL Item
Vysis/path Vysion[tm] (Vysis)
CL Item
Ventana/oncorprobe[tm] (Ventana)
CL Item
Other, Specify (Other, specify)
FISHKitorTestType,Other
Item
Other, specify (FISH Kit)
double
Item Group
Testing Results
Item
Her-2/neu Status
text
CL.8
Code List
Her-2/neu Status
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
IHC Lab value
text
CL.9
Code List
IHC Lab value
CL Item
0 (0 or 0% cells staining)
C0919414 (NCI Metathesaurus)
CL Item
1+ (1 or 1-10% cells staining)
CL Item
2+ (2 or 11-49% cells staining)
CL Item
3+ (3 or 50-100% cells staining)
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
Item Group
Ccrr Module For Calgb: Her-2/neu Status Form
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