ID
10615
Beskrivning
CALGB: 49903 Advanced Disease On-study Form NCT00053339 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=A73D2625-44FB-4784-E034-0003BA0B1A09
Länk
Nyckelord
Versioner (3)
- 2012-08-26 2012-08-26 -
- 2015-05-22 2015-05-22 -
- 2015-06-03 2015-06-03 -
Uppladdad den
3 juni 2015
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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CALGB: 49903 Advanced Disease On-study Form NCT00053339
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. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Beskrivning
Patient clinical trial data
Beskrivning
Patient'sName
Datatyp
text
Beskrivning
ParticipatingGroup
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beskrivning
PatientHospitalNumber
Datatyp
text
Beskrivning
ParticipatingGroupProtocolNo.
Datatyp
text
Beskrivning
AffiliateName
Datatyp
text
Beskrivning
ParticipatingGroupPatientID
Datatyp
text
Beskrivning
MenopausalStatus
Datatyp
text
Beskrivning
Advanced Disease Description
Beskrivning
ERStatus
Datatyp
text
Beskrivning
ERTiming,Other
Datatyp
text
Beskrivning
PgRStatus
Datatyp
text
Beskrivning
ReceptorStatusTiming
Datatyp
text
Beskrivning
ReceptorStatusTiming
Datatyp
text
Beskrivning
PgRTiming,Other
Datatyp
text
Beskrivning
FirstPositiveBiopsyDate
Datatyp
date
Beskrivning
RecurrenceDate
Datatyp
date
Beskrivning
Sites Of Progression
Beskrivning
ProgressionSite
Datatyp
text
Beskrivning
ProgressionSite,Other
Datatyp
text
Beskrivning
Priorsystemictherapy
Datatyp
text
Beskrivning
PriorTreatmentRegimenName(s)
Datatyp
text
Beskrivning
PriorTreatmentRegimenBeginDate
Datatyp
date
Beskrivning
PriorTreatmentRegimenEndDate
Datatyp
date
Beskrivning
PriorTreatmentRegimenType
Datatyp
text
Beskrivning
Laboratory
Beskrivning
Lab,Hematology,GranulocyteCount
Datatyp
double
Beskrivning
Lab,Hepatic,Bilirubin
Datatyp
double
Beskrivning
Lab,Renal,Creatinine
Datatyp
double
Beskrivning
Lab,Hematology,Platelets
Datatyp
double
Beskrivning
Bilirubin(mg/dl),ULN
Datatyp
double
Alias
- NCI Thesaurus ValueDomain
- C25712
- UMLS 2011AA ValueDomain
- C1522609
- NCI Thesaurus ValueDomain
- C25706
- UMLS 2011AA ValueDomain
- C1519815
Beskrivning
Lab,Cardiovascular,LVEF
Datatyp
text
Beskrivning
Lab,Hepatic,AlkalinePhosphatase
Datatyp
double
Beskrivning
Lab,Hepatic,SGOT
Datatyp
double
Beskrivning
Lab,Hepatic,SGPT
Datatyp
double
Beskrivning
PersonCompletingForm,FirstName
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beskrivning
FormCompletionDate,Original
Datatyp
date
Beskrivning
%LowerlimitofinstitutionalnormalLVEF
Datatyp
text
Beskrivning
Ccrr Module For Calgb: 49903 Advanced Disease On-study Form
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. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0205160 (UMLS 2011AA)
C1446409 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0205160 (UMLS 2011AA)
C1446409 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C0262950 (UMLS 2011AA)
C0005953 (UMLS 2011AA)
C0024109 (UMLS 2011AA)
C0023884 (UMLS 2011AA)
C0281265 (UMLS 2011AA)
C1514455 (UMLS 2011AA)
C1514456 (UMLS 2011AA)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain)
C1519815 (UMLS 2011AA ValueDomain)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)