ID

11622

Description

NSABP PROTOCOL B-35 Treatment of Ipsilateral or Contralateral Breast Event 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=A019BB52-B911-3D6B-E034-080020C9C0E0

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A019BB52-B911-3D6B-E034-080020C9C0E0

Mots-clés

Versions (3)
  1. 26/08/2012 26/08/2012 -
  2. 08/07/2015 08/07/2015 -
  3. 08/07/2015 08/07/2015 -
Téléchargé le

8 juillet 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Retour au modèle Commentaires
Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

NSABP PROTOCOL B-35 Treatment of Ipsilateral or Contralateral Breast Event

Anglais

Form T2 (04-30-2002) Submit this form to report treatment undertaken within 6 months of diagnosis of any invasive or non-invasive Ipsilateral Breast Tumor Recurrence (IBTR) or Cancer in Opposite Breast.

1 Formulaires  
Header module
Description

Header module

First Three Letters of Patient's Last Name
Description

First Three Letters of Patient's Last Name

Type de données

float

Alias
UMLS CUI-1
C1299487
Patient Study ID
Description

Patient Study ID

Type de données

float

Alias
UMLS CUI-1
C2348585
Institution Name
Description

Institution Name

Type de données

text

Alias
UMLS CUI-1
C0018704
UMLS CUI-2
C0600091
Affiliate Name
Description

Affiliate Name

Type de données

text

Alias
UMLS CUI-1
C1510825
UMLS CUI-2
C0600091
Person Completing Form Last Name
Description

Person Completing Form Last Name

Type de données

text

Alias
UMLS CUI-1
C3258039
Person Completing Form First Name
Description

Person Completing Form First Name

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25364
UMLS CUI-1
C3258039
UMLS CUI-2
C1443235
Person Completing Form Phone
Description

PersonCompletingForm,Phone

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Are data amended? (If Yes, circle the amended items in red.)
Description

Are data amended? (If Yes, circle the amended items in red.)

Type de données

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI-1
C1511726
UMLS CUI-2
C1691222
Event for which Treatment is Reported
Description

Event for which Treatment is Reported

Type de données

text

Alias
UMLS CUI-1
C1443309
Date of this IBTR or Cancer in Opposite Breast (month day year If this event has not yet been reported on a follow-up form, complete and attach Form F35.)
Description

Date of this IBTR or Cancer in Opposite Breast (month day year If this event has not yet been reported on a follow-up form, complete and attach Form F35.)

Type de données

date

Alias
UMLS CUI-1
C0011008
UMLS CUI-2
C0006142
Breast Cancer Therapeutic Procedure
Description

Breast Cancer Therapeutic Procedure

Alias
UMLS CUI-1
C1511300
Total Mastectomy
Description

Total Mastectomy

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0554403
Lumpectomy
Description

Lumpectomy

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0740370
Breast Radiation
Description

Breast Radiation

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C2540969
Regional Radiation
Description

Regional Radiation

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0807734
Hormonal Therapy
Description

Hormonal Therapy

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0877050
Chemotherapy
Description

Chemotherapy

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0392920
Other (specify)
Description

Other (specify)

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
UMLS CUI-1
C0418967
specify
Description

specify

Type de données

text

Alias
UMLS CUI-1
C3845569
Retour au début de la page

Similar models

Form T2 (04-30-2002) Submit this form to report treatment undertaken within 6 months of diagnosis of any invasive or non-invasive Ipsilateral Breast Tumor Recurrence (IBTR) or Cancer in Opposite Breast.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header module
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
float
C1299487 (UMLS CUI-1)
PatientStudyID
Item
Patient Study ID
float
C2348585 (UMLS CUI-1)
InstitutionName
Item
Institution Name
text
C0018704 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
AffiliateName
Item
Affiliate Name
text
C1510825 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
PersonCompletingForm,LastName
Item
Person Completing Form Last Name
text
C3258039 (UMLS CUI-1)
PersonCompletingForm,FirstName
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C3258039 (UMLS CUI-1)
C1443235 (UMLS CUI-2)
PersonCompletingForm,Phone
Item
Person Completing Form Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
AmendedDataInd
Item
Are data amended? (If Yes, circle the amended items in red.)
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
Item
Event for which Treatment is Reported
text
C1443309 (UMLS CUI-1)
CL.2
Code List
Event for which Treatment is Reported
CL Item
Ipsilateral Breast Tumor Recurrence (ibtr) (Ipsilateral Breast Tumor Recurrence (IBTR))
C0006142 (UMLS CUI-1)
C1458156 (UMLS CUI-2)
CL Item
cst (Cancer in Opposite Breast)
C1096616 (UMLS CUI-1)
occurrence date of current caner
Item
Date of this IBTR or Cancer in Opposite Breast (month day year If this event has not yet been reported on a follow-up form, complete and attach Form F35.)
date
C0011008 (UMLS CUI-1)
C0006142 (UMLS CUI-2)
Item Group
Breast Cancer Therapeutic Procedure
C1511300 (UMLS CUI-1)
Item
Total Mastectomy
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0554403 (UMLS CUI-1)
CL.3
Code List
Total Mastectomy
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Lumpectomy
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0740370 (UMLS CUI-1)
CL.4
Code List
Lumpectomy
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Breast Radiation
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C2540969 (UMLS CUI-1)
CL.5
Code List
Breast Radiation
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Regional Radiation
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0807734 (UMLS CUI-1)
CL.6
Code List
Regional Radiation
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Hormonal Therapy
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0877050 (UMLS CUI-1)
CL.7
Code List
Hormonal Therapy
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Chemotherapy
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0392920 (UMLS CUI-1)
CL.8
Code List
Chemotherapy
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Other (specify)
text
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C0418967 (UMLS CUI-1)
CL.9
Code List
Other (specify)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
TreatmentType,Specify
Item
specify
text
C3845569 (UMLS CUI-1)
Retour au début de la page 

Contact

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Aide

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial