ID

22246

Description

AMC-045 Off Study Summary Form (F50) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7284A0F2-BE74-FDEC-E040-BB89AD43537B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7284A0F2-BE74-FDEC-E040-BB89AD43537B

Keywords

  1. 8/26/12 8/26/12 -
  2. 5/24/17 5/24/17 - Martin Dugas
Uploaded on

May 24, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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AMC-045 Off Study Summary Form (F50)

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

Off Study Summary
Description

Off Study Summary

Alias
UMLS CUI-1
C1518546
UMLS CUI-2
C1706244
Off Study Date
Description

Off-Treatment Study Follow-Up End Date

Data type

date

Measurement units
  • mm/dd/yyyy
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass
C15206
NCI Thesaurus Property
C25275
UMLS CUI [1]
C2985813
mm/dd/yyyy
Off Study Reason (select the primary reason)
Description

Off Study Reason Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass
C15206
UMLS CUI [1,1]
C2985814
Off-Treatment Study Follow-Up Specify
Description

Off Treatment Reason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C16033
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus ObjectClass
C15206
UMLS CUI [1,1]
C2985814
UMLS CUI [1,2]
C1521902
Research Comments
Description

Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1]
C0947611

Similar models

Please submit this form if the subject has (at least one of the following): 1) completed the post treatment follow-up period per protocol 2) been lost to follow-up 3) has refused follow-up 4) withdrew consent 5) has died. (Note: If all follow-up for a subject has been completed, all subjects (except those never initiating protocol therapy) must have both an Off Protocol Treatment Summary form and Off Study Summary form submitted.)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Off Study Summary
C1518546 (UMLS CUI-1)
C1706244 (UMLS CUI-2)
Off Study Date
Item
Off Study Date
date
C25164 (NCI Thesaurus ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C2985813 (UMLS CUI [1])
Item
Off Study Reason (select the primary reason)
text
C25638 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass)
C2985814 (UMLS CUI [1,1])
Code List
Off Study Reason (select the primary reason)
CL Item
Protocol-defined Follow-up Completed (Protocol-defined follow-up completed)
C1522577 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
CL Item
Lost To Follow-up (Patient lost to follow-up)
CL310949 (NCI Metathesaurus)
C1302313 (UMLS CUI-1)
CL Item
Patient Refused Follow-up (Patient refused follow-up)
C0580699 (UMLS CUI-1)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS CUI-1)
CL Item
Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
C0877248 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
Off Treatment Reason
Item
Off-Treatment Study Follow-Up Specify
text
C25685 (NCI Thesaurus ValueDomain)
C16033 (NCI Thesaurus Property)
C25601 (NCI Thesaurus ObjectClass)
C15206 (NCI Thesaurus ObjectClass)
C2985814 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Comments
Item
Research Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1])

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