ID
10616
Description
CALGB: 49903 ADVANCED FOLLOW-UP 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=A73D2007-5070-476F-E034-0003BA0B1A09
Lien
Mots-clés
Versions (3)
- 26/08/2012 26/08/2012 -
- 22/05/2015 22/05/2015 -
- 03/06/2015 03/06/2015 -
Téléchargé le
3 juin 2015
DOI
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Licence
Creative Commons BY-NC 3.0 Legacy
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CALGB: 49903 ADVANCED FOLLOW-UP 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.
Description
Patient clinical trial data
Description
Patient'sName
Type de données
text
Description
ParticipatingGroup
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Type de données
text
Description
ParticipatingGroupProtocolNo.
Type de données
text
Description
AffiliateName
Type de données
text
Description
ParticipatingGroupPatientID
Type de données
text
Description
Cancer follow up
Description
Patient'sVitalStatus
Type de données
text
Description
DeathReason
Type de données
text
Description
DeathDate/LastContactDate
Type de données
date
Description
CancerFollow-upStatusInd
Type de données
text
Description
CancerFollow-upStatusDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Description
OverallTumorResponse
Type de données
text
Description
ResponseDurationBeginDate
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C25755
- UMLS 2011AA ObjectClass
- C0871261
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Description
ProgressionInd
Type de données
text
Description
ProgressionDate
Type de données
date
Description
Non-protocol Therapy
Description
Non-ProtocolTherapyInd
Type de données
text
Description
Non-ProtocolHormonalTherapyInd
Type de données
text
Description
OtherNon-ProtocolTherapyName
Type de données
text
Description
Non-ProtocolTherapyDate,First
Type de données
date
Description
AgentEndDate
Type de données
date
Description
Comments
Type de données
text
Description
PersonCompletingForm,FirstName
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
FormCompletionDate,Original
Type de données
date
Description
Ccrr Module For Calgb: 49903 Advanced Follow-up 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)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0677946 (UMLS 2011AA)
C0871261 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)