Informatie:
Fout:
ID
10612
Beschrijving
NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole NCT00053898 Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051E957-2260-0392-E034-080020C9C0E0
Link
Trefwoorden
Versies (3)
- 26-08-12 26-08-12 -
- 22-05-15 22-05-15 -
- 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.
Itemgroep Commentaren voor :
Item Commentaren voor :
U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.
NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole NCT00053898
Form T (04-30-2002) Submit this form when Tamoxifen/Anastrozole therapy has ended or if the patient did not begin Tamoxifen/Anastrozole.
- StudyEvent: NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole
Similar models
Form T (04-30-2002) Submit this form when Tamoxifen/Anastrozole therapy has ended or if the patient did not begin Tamoxifen/Anastrozole.
- StudyEvent: NSABP PROTOCOL B-35 Treatment Form for Tamoxifen/Anastrozole
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
text
PatientStudyID
Item
Patient Study ID
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PersonCompletingForm,LastName
Item
Person Completing Form Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PersonCompletingForm,Phone
Item
Person Completing Form Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Are data amended? (If Yes, circle the amended items in red.)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item Group
Summary Of Tamoxifen/anastrozole Administration
TreatmentBeginDate
Item
Treatment Begin Date (0=not begun Month Day Year)
date
TreatmentEndDate
Item
Treatment End Date (0=not begun Month Day Year )
date
Item
Reason Treatment Ended (Select the reason that best explains why treatment has ended, or why the patient did not begin treatment.)
text
Code List
Reason Treatment Ended (Select the reason that best explains why treatment has ended, or why the patient did not begin treatment.)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
OffTreatmentReason,Other
Item
Other
text