ID

11619

Description

ECOG Second Primary Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC346EE2-C452-2587-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC346EE2-C452-2587-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 08/07/2015 08/07/2015 -
Téléchargé le

8 juillet 2015

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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ECOG Second Primary Form (E2100)

Anglais

Form No. 630

1 Formulaires  
  1. StudyEvent: ECOG Second Primary Form (E2100)
    1. Form No. 630
ECOG data
Description

ECOG data

ECOG Patient ID
Description

ECOG Patient ID

Type de données

float

Alias
UMLS CUI-1
C1512162
UMLS CUI-2
C1830427
Registration Step
Description

RegistrationStep

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Patient's Name
Description

Patient's Name

Type de données

text

Alias
UMLS CUI-1
C1299487
Participating Group Protocol No.
Description

Participating Group Protocol No.

Type de données

float

Alias
UMLS CUI-1
C2826693
UMLS CUI-2
C3274381
Participating Group Patient ID
Description

Participating Group Patient ID

Type de données

integer

Alias
UMLS CUI-1
C2348585
Institution/Affiliate
Description

Institution/Affiliate

Type de données

text

Alias
UMLS CUI-1
C1301943
ECOG Protocol No.
Description

ECOG Protocol No.

Type de données

float

Alias
UMLS CUI-1
C1512162
UMLS CUI-2
C2348585
Are data amended?
Description

Are data amended?

Type de données

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI-1
C1511726
UMLS CUI-2
C1691222
Second Primary Cancers
Description

Second Primary Cancers

Date of Diagnosis of Second Primary Cancer (M D Y)
Description

Date of Diagnosis of Second Primary Cancer (M D Y)

Type de données

date

Alias
UMLS CUI-1
C2316983
UMLS CUI-2
C0751623
Site of Second Primary Cancer
Description

Site of Second Primary Cancer

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25251
NCI Thesaurus ObjectClass-2
C9305
NCI Thesaurus ObjectClass-3
C25666
NCI Thesaurus Property
C25341
NCI Thesaurus Property-2
C25421
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1515974
UMLS CUI-2
C0751623
Include information on histologic subtype(s). (Please attach copies of any corroborating pathology reports.)
Description

Include information on histologic subtype(s). (Please attach copies of any corroborating pathology reports.)

Type de données

text

Alias
UMLS CUI-1
C0449574
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
Description

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols

Type de données

text

Alias
UMLS CUI-1
C0920425
UMLS CUI-2
C0332132
UMLS CUI-3
C0751623
Briefly describe treatment planned or given for the diagnosis of this second primary
Description

Briefly describe treatment planned or given for the diagnosis of this second primary

Type de données

text

Alias
UMLS CUI-1
C0920425
Comments
Description

Comments

Comments
Description

Comments

Type de données

text

Alias
UMLS CUI-1
C0947611
Investigator Signature
Description

Investigator Signature

Type de données

text

Alias
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
UMLS CUI-1
C1519316
UMLS CUI-2
C0035173
Date
Description

Date

Type de données

date

Alias
UMLS CUI-1
C0011008
Ccrr Module For Ecog Second Primary Form (e2100)
Description

Ccrr Module For Ecog Second Primary Form (e2100)

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Similar models

Form No. 630

1 Formulaires
  1. StudyEvent: ECOG Second Primary Form (E2100)
    1. Form No. 630
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
ECOG data
ECOGPatientID
Item
ECOG Patient ID
float
C1512162 (UMLS CUI-1)
C1830427 (UMLS CUI-2)
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain-2)
C1704379 (UMLS 2011AA ValueDomain-2)
Patient'sName
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
float
C2826693 (UMLS CUI-1)
C3274381 (UMLS CUI-2)
ParticipatingGroupPatientID
Item
Participating Group Patient ID
integer
C2348585 (UMLS CUI-1)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
C1301943 (UMLS CUI-1)
ECOG Protocol No.
Item
ECOG Protocol No.
float
C1512162 (UMLS CUI-1)
C2348585 (UMLS CUI-2)
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
Item Group
Second Primary Cancers
DateofDiagnosisofSecondPrimaryCancer
Item
Date of Diagnosis of Second Primary Cancer (M D Y)
date
C2316983 (UMLS CUI-1)
C0751623 (UMLS CUI-2)
Second Primary Malignant Neoplasm Anatomic Site
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C25341 (NCI Thesaurus Property)
C25421 (NCI Thesaurus Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1515974 (UMLS CUI-1)
C0751623 (UMLS CUI-2)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s). (Please attach copies of any corroborating pathology reports.)
text
C0449574 (UMLS CUI-1)
cancer therapy prior to diagnosis
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
text
C0920425 (UMLS CUI-1)
C0332132 (UMLS CUI-2)
C0751623 (UMLS CUI-3)
Treatment planned/given
Item
Briefly describe treatment planned or given for the diagnosis of this second primary
text
C0920425 (UMLS CUI-1)
Item Group
Comments
Comments
Item
Comments
text
C0947611 (UMLS CUI-1)
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C1519316 (UMLS CUI-1)
C0035173 (UMLS CUI-2)
Date
Item
Date
date
C0011008 (UMLS CUI-1)
Item Group
Ccrr Module For Ecog Second Primary Form (e2100)
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