ID

606

Description

NCI Cooperative Group Follow-Up Form (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C23658-5AE0-303F-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C23658-5AE0-303F-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
Téléchargé le

26 août 2012

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT00014534 Follow-Up - NCI Cooperative Group Follow-Up Form (CALGB-90104) - 2056490v3.0

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
    1. No Instruction available.
Mskcc 00-138; Calgb-90104; Ecog
Description

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Description

CoordinatingGroupProtocolNumber

Type de données

text

Coordinating Group Code
Description

CoordinatingGroupCode

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Description

ProtocolTitle

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Type de données

text

Patient Study ID, Participating Group
Description

PatientStudyID,ParticipatingGroup

Type de données

text

Participating Group Code
Description

ParticipatingGroupCode

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Institution Name
Description

InstitutionName

Type de données

text

Affiliate
Description

AffiliateName

Type de données

text

Patient Last Name (initials acceptable)
Description

PatientName,Last

Type de données

text

Patient First Name (initials acceptable)
Description

PatientName,First

Type de données

text

Patient Middle Name (initials acceptable)
Description

PatientName,Middle

Type de données

text

Form Administration
Description

Form Administration

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Type de données

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended?
Description

AmendedDataInd

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Vital Status
Description

Vital Status

Patient's Vital Status
Description

Patient'sVitalStatus

Type de données

text

Primary Cause of Death (check one)
Description

DeathReason

Type de données

text

Describe cause of death
Description

DeathReason,Specify

Type de données

text

Date of Last Contact or Death (MM DD YYYY)
Description

DeathDate/LastContactDate

Type de données

date

Disease Follow-up Status
Description

Disease Follow-up Status

Has the patient had a documented clinical assessment for this cancer?
Description

CancerFollow-upStatusInd

Type de données

text

Date of Last Clinical Assessment (MM DD YYYY)
Description

CancerFollow-upStatusDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Chest X-ray Assessment Date
Description

ChestX-RayAssessmentDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Abdominal/Pelvic CT Assessment Date
Description

Abdominal/PelvicCTAssessmentDate

Type de données

text

Notice Of Progression
Description

Notice Of Progression

Has the patient been diagnosed with a local recurrence that has not been previously reported?
Description

ProgressionInd,LocalAdvanced

Type de données

text

Date of First Local Progression (MM DD YYYY)
Description

ProgressionDate,FirstLocal

Type de données

date

Site(s) of First Local Progression (mark all that apply)
Description

ProgressionSite,FirstLocal

Type de données

text

Other, specify
Description

ProgressionSite,FirstLocal,Other

Type de données

text

Has the patient been diagnosed with a local-regional lymph node recurrence?
Description

ProgressionInd,LocalNodes

Type de données

text

Date of First Local-Regional Lymph Node Progression (MM DD YYYY)
Description

ProgressionDate,FirstLocalNode

Type de données

date

Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
Description

ProgressionSite,FirstLocalNode

Type de données

text

Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
Description

ProgressionInd,DistantMetastatic

Type de données

text

Date of First Distant Progression (MM DD YYYY)
Description

ProgressionDate,FirstDistant

Type de données

date

Site(s) of First Distant Progression (mark all that apply)
Description

ProgressionSite,FirstDistant

Type de données

text

Distant nodes, specify
Description

LymphNodes,DistantLocation

Type de données

text

Other, specify
Description

Other,specify

Type de données

text

Other, specify
Description

Other,specify

Type de données

text

Notice Of New Primary
Description

Notice Of New Primary

Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Description

NewPrimaryCancerInd

Type de données

text

Date of Diagnosis (MM DD YYYY)
Description

NewPrimaryCancerDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Site(s) of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
Description

NewPrimarySite

Type de données

text

Notice Of Long Term Toxicity
Description

Notice Of Long Term Toxicity

Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
Description

LateAdverseEventInd

Type de données

text

Late Adverse Event Term
Description

LateAdverseEventTerm

Type de données

text

Late Adverse Event Grade
Description

LateAdverseEventGrade

Type de données

text

Date of Onset of Long-Term Toxicity
Description

LateAdverseEventOnsetDate

Type de données

date

Comments
Description

Comments

Comments
Description

Comments

Type de données

text

Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)
Description

Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)

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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Mskcc 00-138; Calgb-90104; Ecog
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
ProtocolTitle
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate
text
PatientName,Last
Item
Patient Last Name (initials acceptable)
text
PatientName,First
Item
Patient First Name (initials acceptable)
text
PatientName,Middle
Item
Patient Middle Name (initials acceptable)
text
Item Group
Form Administration
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Vital Status
Item
Patient's Vital Status
text
CL.2
Code List
Patient's Vital Status
CL Item
Alive (Alive-NED)
CL Item
Alive (Alive with Disease)
CL Item
Dead (Dead)
Item
Primary Cause of Death (check one)
text
CL.3
Code List
Primary Cause of Death (check one)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Due to other cause (Due to other cause)
DeathReason,Specify
Item
Describe cause of death
text
DeathDate/LastContactDate
Item
Date of Last Contact or Death (MM DD YYYY)
date
Item Group
Disease Follow-up Status
Item
Has the patient had a documented clinical assessment for this cancer?
text
CL.4
Code List
Has the patient had a documented clinical assessment for this cancer?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (MM DD YYYY)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
ChestX-RayAssessmentDate
Item
Chest X-ray Assessment Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Abdominal/PelvicCTAssessmentDate
Item
Abdominal/Pelvic CT Assessment Date
text
Item Group
Notice Of Progression
Item
Has the patient been diagnosed with a local recurrence that has not been previously reported?
text
CL.5
Code List
Has the patient been diagnosed with a local recurrence that has not been previously reported?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
ProgressionDate,FirstLocal
Item
Date of First Local Progression (MM DD YYYY)
date
Item
Site(s) of First Local Progression (mark all that apply)
text
CL.6
Code List
Site(s) of First Local Progression (mark all that apply)
CL Item
abdominal wall (abdominal wall)
CL Item
prostate (prostate)
CL Item
urethra (urethra)
CL Item
pelvic wall (pelvic wall)
CL Item
skin (skin)
CL Item
Uterus (uterus)
CL Item
Peritoneum (peritoneum)
CL Item
vagina (vagina)
CL Item
Other, Specify (other, specify)
ProgressionSite,FirstLocal,Other
Item
Other, specify
text
Item
Has the patient been diagnosed with a local-regional lymph node recurrence?
text
CL.7
Code List
Has the patient been diagnosed with a local-regional lymph node recurrence?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
ProgressionDate,FirstLocalNode
Item
Date of First Local-Regional Lymph Node Progression (MM DD YYYY)
date
Item
Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
text
CL.8
Code List
Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
CL Item
Disease Is Present In The Internal Iliac Lymph Nodes (internal iliac)
CL Item
Disease Is Present In The External Iliac Lymph Nodes (external iliac)
CL Item
Disease Is Present In The Common Iliac Lymph Nodes (common iliac)
CL Item
Disease Is Present In The Hypogastric Lymph Nodes (hypogastric)
CL Item
Disease Is Present In The Para-aortic Lymph Nodes (para-aortic)
CL Item
Disease Is Present In Another Local-regional Lymph Nodes, Specify (other, specify)
Item
Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
text
CL.9
Code List
Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Date of First Distant Progression (MM DD YYYY)
date
Item
Site(s) of First Distant Progression (mark all that apply)
text
CL.10
Code List
Site(s) of First Distant Progression (mark all that apply)
CL Item
Bone (bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Liver (liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Peritoneum (peritoneum)
CL Item
Pleura (pleura)
CL Item
Skin (skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Central Nervous System (central nervous system/brain)
CL Item
Lymph Nodes (distant) (distant nodes, specify)
CL Item
other, specify (other, specify)
LymphNodes,DistantLocation
Item
Distant nodes, specify
text
Other,specify
Item
Other, specify
text
Other,specify
Item
Other, specify
text
Item Group
Notice Of New Primary
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
CL.11
Code List
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of Diagnosis (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Site(s) of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
text
Item Group
Notice Of Long Term Toxicity
Item
Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
text
CL.12
Code List
Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
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)
LateAdverseEventTerm
Item
Late Adverse Event Term
text
LateAdverseEventGrade
Item
Late Adverse Event Grade
text
LateAdverseEventOnsetDate
Item
Date of Onset of Long-Term Toxicity
date
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)
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