ID
10818
Description
E1105 Cardiac Toxicity Form NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=171FF705-FB7F-3F20-E044-0003BA3F9857
Link
Keywords
Versions (3)
- 8/26/12 8/26/12 -
- 1/8/15 1/8/15 - Martin Dugas
- 6/8/15 6/8/15 -
Uploaded on
June 8, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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E1105 Cardiac Toxicity Form NCT00520975
INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files
- StudyEvent: E1105 Cardiac Toxicity Form
Description
Patient demographics
Description
Patient Initials
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Description
Protocol Number ECOG
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C1512162
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25491
Description
Patient ID ECOG
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C1512162
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25491
Description
Study Number Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Trial subject ID Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Institution Name
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS CUI-1
- C1301943
- NCI Thesaurus ObjectClass-2
- C21541
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25191
- NCI Thesaurus ValueDomain-2
- C21541
Description
Data amendment
Description
Data amended
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- NCI Thesaurus Property
- C25416
Description
Data amended date
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0680532
- NCI Thesaurus ObjectClass
- C25474
- UMLS CUI-2
- C0011008
- NCI Thesaurus Property
- C25416
- NCI Thesaurus ValueDomain-2
- C25367
Description
On Treatment
Description
Cycle number
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2045829
- NCI Thesaurus Property
- C25214
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ObjectClass
- C15368
Description
Chemotherapy cycle
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25214
- UMLS CUI-1
- C1302181
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ValueDomain
- C25685
- NCI Thesaurus ValueDomain-2
- C25472
- NCI Thesaurus ValueDomain-3
- C25275
Description
Off Treatment
Description
PersonOff-TreatmentTimePeriodType
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus Property-2
- C25601
- UMLS 2011AA Property-2
- C1518544
- NCI Thesaurus Property-3
- C25207
- UMLS 2011AA Property-3
- C0040223
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
Cardiovascular assessment
Description
CardiacPerformanceStatusAssessmentInd-2
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus ObjectClass
- C13306
- UMLS 2011AA ObjectClass
- C1522601
- NCI Metathesaurus ObjectClass
- CL092952
Description
CardiacPerformanceStatusAssessmentMostRecentDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C13306
- UMLS 2011AA ObjectClass
- C1522601
- NCI Metathesaurus ObjectClass
- CL092952
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain-2
- C25577
- UMLS 2011AA ValueDomain-2
- C1513491
Description
Evaluation method
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2911685
- NCI Thesaurus ObjectClass
- C20989
- NCI Thesaurus Property
- C16847
Description
HeartLVEFTestPercentageValue
Data type
float
Measurement units
- %
Alias
- NCI Thesaurus ObjectClass
- C12727
- UMLS 2011AA ObjectClass
- C0018787
- NCI Thesaurus Property
- C25294
- UMLS 2011AA Property
- C0022885
- NCI Thesaurus Property-2
- C37946
- UMLS 2011AA Property-2
- C2700377
- NCI Thesaurus ValueDomain
- C25613
- UMLS 2011AA ValueDomain
- C0439165
- NCI Thesaurus ValueDomain-2
- C25712
- UMLS 2011AA ValueDomain-2
- C1522609
Description
HeartLVEFTestPercentageLowerLimitofNormalValue
Data type
float
Measurement units
- %
Alias
- NCI Thesaurus ObjectClass
- C12727
- UMLS 2011AA ObjectClass
- C0018787
- NCI Thesaurus Property
- C25294
- UMLS 2011AA Property
- C0022885
- NCI Thesaurus Property-2
- C37946
- UMLS 2011AA Property-2
- C2700377
- NCI Thesaurus ValueDomain
- C25613
- UMLS 2011AA ValueDomain
- C0439165
- NCI Thesaurus ValueDomain-2
- C25712
- UMLS 2011AA ValueDomain-2
- C1522609
- NCI Thesaurus ValueDomain-3
- C25555
- UMLS 2011AA ValueDomain-3
- C1518030
Description
HeartLVEFTestDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C12727
- UMLS 2011AA ObjectClass
- C0018787
- NCI Thesaurus Property
- C25294
- UMLS 2011AA Property
- C0022885
- NCI Thesaurus Property-2
- C37946
- UMLS 2011AA Property-2
- C2700377
Description
ThirdSoundGallopAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus ObjectClass-2
- C61455
- UMLS 2011AA ObjectClass-2
- C0232237
Description
DyspneaAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus ObjectClass-2
- C2998
- UMLS 2011AA ObjectClass-2
- C0013404
Description
BasilarRalesAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus ObjectClass-2
- C61454
- UMLS 2011AA ObjectClass-2
- C0240859
Description
CardiomegalyAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus ObjectClass-2
- C61453
- UMLS 2011AA ObjectClass-2
- C0018800
Description
CongestiveHeartFailureAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C41331
- UMLS 2011AA ObjectClass
- C0877248
- NCI Thesaurus ObjectClass-2
- C3080
- UMLS 2011AA ObjectClass-2
- C0018802
Description
AbnormalElectrocardiographyAdverseEventPresentInd-3
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25401
- UMLS 2011AA ObjectClass
- C0205161
- NCI Thesaurus ObjectClass-2
- C41331
- UMLS 2011AA ObjectClass-2
- C0877248
- NCI Thesaurus ObjectClass-3
- C38053
- UMLS 2011AA ObjectClass-3
- C1623258
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
AbnormalElectrocardiographyAdverseEventPresentSpecify
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25401
- UMLS 2011AA ObjectClass
- C0205161
- NCI Thesaurus ObjectClass-2
- C41331
- UMLS 2011AA ObjectClass-2
- C0877248
- NCI Thesaurus ObjectClass-3
- C38053
- UMLS 2011AA ObjectClass-3
- C1623258
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
Description
Comments
Description
Investigator Signature
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Description
Investigator Signature Date
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- UMLS CUI-2
- C0011008
- NCI Thesaurus ValueDomain-2
- C25367
- NCI Thesaurus ObjectClass
- C17089
Similar models
INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files
- StudyEvent: E1105 Cardiac Toxicity Form
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C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
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C1512162 (UMLS CUI-2)
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C25472 (NCI Thesaurus ValueDomain-2)
C25275 (NCI Thesaurus ValueDomain-3)
C0027361 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25601 (NCI Thesaurus Property-2)
C1518544 (UMLS 2011AA Property-2)
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C0040223 (UMLS 2011AA Property-3)
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C1513491 (UMLS 2011AA ValueDomain-2)
C2911685 (UMLS CUI-1)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
C2243117 (UMLS 2011AA)
C0018787 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C37946 (NCI Thesaurus Property-2)
C2700377 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
C0018787 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C37946 (NCI Thesaurus Property-2)
C2700377 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
C25555 (NCI Thesaurus ValueDomain-3)
C1518030 (UMLS 2011AA ValueDomain-3)
C0011008 (UMLS 2011AA ValueDomain)
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C0018787 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C37946 (NCI Thesaurus Property-2)
C2700377 (UMLS 2011AA Property-2)
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C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
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C0877248 (UMLS 2011AA ObjectClass)
C61455 (NCI Thesaurus ObjectClass-2)
C0232237 (UMLS 2011AA ObjectClass-2)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C2998 (NCI Thesaurus ObjectClass-2)
C0013404 (UMLS 2011AA ObjectClass-2)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C61454 (NCI Thesaurus ObjectClass-2)
C0240859 (UMLS 2011AA ObjectClass-2)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C61453 (NCI Thesaurus ObjectClass-2)
C0018800 (UMLS 2011AA ObjectClass-2)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
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C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0205161 (UMLS 2011AA ObjectClass)
C41331 (NCI Thesaurus ObjectClass-2)
C0877248 (UMLS 2011AA ObjectClass-2)
C38053 (NCI Thesaurus ObjectClass-3)
C1623258 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0205161 (UMLS 2011AA ObjectClass)
C41331 (NCI Thesaurus ObjectClass-2)
C0877248 (UMLS 2011AA ObjectClass-2)
C38053 (NCI Thesaurus ObjectClass-3)
C1623258 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
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C1521902 (UMLS 2011AA ValueDomain)
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C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)