ID

10571

Beschrijving

S0023 ZD1839 DOSE AND TOXICITY REPORTING FORM NCT00020709 S0023: Combination Chemo Plus RT With or Without Gefitinib in Treating Patients With Unresectable Stage III NSCLC Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CA62D43-50BE-361C-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CA62D43-50BE-361C-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

3 juni 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

S0023 ZD1839 DOSE AND TOXICITY REPORTING FORM NCT00020709

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0023 ZD1839 DOSE AND TOXICITY REPORTING FORM
    1. No Instruction available.
SWOG clinical trial administrative data
Beschrijving

SWOG clinical trial administrative data

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Submission Time
Beschrijving

SubmissionTime:

Datatype

text

Patient Initials (L, F,M)
Beschrijving

PatientInitials

Datatype

text

Institution / Affiliate
Beschrijving

Institution/Affiliate

Datatype

text

Physician
Beschrijving

Physician

Datatype

text

Group Name (Groups other than SWOG )
Beschrijving

GroupName

Datatype

text

Study No. (Groups other than SWOG )
Beschrijving

StudyNo.

Datatype

double

Pt. ID (Groups other than SWOG )
Beschrijving

Pt.ID

Datatype

text

Treatment
Beschrijving

Treatment

Reporting Begin Date (4 week period)
Beschrijving

ReportingBeginDate:

Datatype

text

Reporting End Date
Beschrijving

ReportingEndDate:

Datatype

text

Were there any dose modifications or additions/deletions to protocol treatment?
Beschrijving

Werethereanydosemodificationsoradditions/deletionstoprotocoltreatment?

Datatype

text

Delay
Beschrijving

Delay:

Datatype

text

Dose reduction
Beschrijving

Dosereduction:

Datatype

text

Total dose for this reporting period (mg ZD1839 1 Tablet = 250 mg)
Beschrijving

Totaldoseforthisreportingperiod:

Datatype

text

Toxicity
Beschrijving

Toxicity

Were toxicities assessed during this time period?
Beschrijving

Weretoxicitiesassessedduringthistimeperiod?

Datatype

text

Date of most recent toxicity assessment
Beschrijving

Dateofmostrecenttoxicityassessment:

Datatype

text

CTC 2.0 Code
Beschrijving

CTC2.0Code

Datatype

text

Toxicity
Beschrijving

Toxicity

Datatype

text

Grade (1 - 5)
Beschrijving

Grade

Datatype

double

Treatment Relation
Beschrijving

TreatmentRelation

Datatype

text

Other Toxicities (specify:)
Beschrijving

OtherToxicities

Datatype

text

Notes
Beschrijving

Notes

Notes
Beschrijving

Notes

Datatype

text

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: S0023 ZD1839 DOSE AND TOXICITY REPORTING FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
SWOG clinical trial administrative data
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
Item
Submission Time
text
CL.1
Code List
Submission Time
CL Item
4 week (First) Submission (4 week (First) Submission)
CL Item
8 week (Second) Submission (8 week (Second) Submission)
CL Item
Other (Other)
PatientInitials
Item
Patient Initials (L, F,M)
text
Institution/Affiliate
Item
Institution / Affiliate
text
Physician
Item
Physician
text
GroupName
Item
Group Name (Groups other than SWOG )
text
StudyNo.
Item
Study No. (Groups other than SWOG )
double
Pt.ID
Item
Pt. ID (Groups other than SWOG )
text
Item Group
Treatment
ReportingBeginDate:
Item
Reporting Begin Date (4 week period)
text
ReportingEndDate:
Item
Reporting End Date
text
Item
Were there any dose modifications or additions/deletions to protocol treatment?
text
CL.2
Code List
Were there any dose modifications or additions/deletions to protocol treatment?
CL Item
No (No)
CL Item
Yes, planned (per protocol guidelines) (Yes, planned (per protocol guidelines))
CL Item
Yes, unplanned (not per protocol guidelines) (Yes, unplanned (not per protocol guidelines))
Item
Delay
text
CL.3
Code List
Delay
CL Item
Yes (Yes)
CL Item
No (No)
Item
Dose reduction
text
CL.4
Code List
Dose reduction
CL Item
Yes (Yes)
CL Item
No (No)
Totaldoseforthisreportingperiod:
Item
Total dose for this reporting period (mg ZD1839 1 Tablet = 250 mg)
text
Item Group
Toxicity
Item
Were toxicities assessed during this time period?
text
CL.5
Code List
Were toxicities assessed during this time period?
CL Item
No (No)
CL Item
Yes (Yes)
Dateofmostrecenttoxicityassessment:
Item
Date of most recent toxicity assessment
text
Item
CTC 2.0 Code
text
CL.6
Code List
CTC 2.0 Code
CL Item
SK11 (SK11)
CL Item
EY01 (EY01)
CL Item
EY02 (EY02)
CL Item
EY30 (EY30)
CL Item
EY40 (EY40)
CL Item
EY99 (EY99)
CL Item
FL40 (FL40)
CL Item
LI00 (LI00)
CL Item
LI12 (LI12)
CL Item
GI00 (GI00)
CL Item
GI01 (GI01)
CL Item
GI10 (GI10)
CL Item
GI20 (GI20)
CL Item
GU50 (GU50)
CL Item
HE00 (HE00)
CL Item
HE10 (HE10)
CL Item
HE20 (HE20)
CL Item
HE30 (HE30)
CL Item
IM00 (IM00)
CL Item
IN00 (IN00)
CL Item
IN05 (IN05)
CL Item
IN30 (IN30)
Item
Toxicity
text
CL.7
Code List
Toxicity
CL Item
Rash/Desquamation (Rash/Desquamation)
CL Item
Conjunctivitis (Conjunctivitis)
CL Item
Keratitis (Keratitis)
CL Item
Tearing (Tearing)
CL Item
Vision, NOS (Vision, NOS)
CL Item
Eye, Other (Eye, Other)
CL Item
Fatigue (Fatigue)
CL Item
Bilirubin increase (Bilirubin increase)
CL Item
SGPT increase (SGPT increase)
CL Item
Nausea (Nausea)
CL Item
Anorexia (Anorexia)
CL Item
Vomiting (Vomiting)
CL Item
Diarrhea (Diarrhea)
CL Item
Creatinine increase (Creatinine increase)
CL Item
Leukopenia (Leukopenia)
CL Item
Thrombocytopenia (Thrombocytopenia)
CL Item
Anemia (Anemia)
CL Item
Neutropenia/granulocytopenia (Neutropenia/granulocytopenia)
CL Item
Allergy/hypersensitivity (Allergy/hypersensitivity)
CL Item
Infection w/o 3-4 neutropenia (Infection w/o 3-4 neutropenia)
CL Item
Infection with 3-4 neutropenia (Infection with 3-4 neutropenia)
CL Item
Febrile neutropenia (Febrile neutropenia)
Grade
Item
Grade (1 - 5)
double
Item
Treatment Relation
text
CL.8
Code List
Treatment Relation
CL Item
unrelated (unrelated)
CL Item
unlikely (unlikely)
CL Item
possible (possible)
CL Item
probable (probable)
CL Item
definite (definite)
OtherToxicities
Item
Other Toxicities (specify:)
text
Item Group
Notes
Notes
Item
Notes
text
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

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