ID

606

Beschrijving

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

Link

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

Trefwoorden

Versies (2)
  1. 26-08-12 26-08-12 -
  2. 08-01-15 08-01-15 - Martin Dugas
Geüploaded op

26 augustus 2012

DOI

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Licentie

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

Engels

No Instruction available.

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

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Beschrijving

CoordinatingGroupProtocolNumber

Datatype

text

Coordinating Group Code
Beschrijving

CoordinatingGroupCode

Datatype

text

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

ProtocolTitle

Datatype

text

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

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Study ID, Participating Group
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

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

InstitutionName

Datatype

text

Affiliate
Beschrijving

AffiliateName

Datatype

text

Patient Last Name (initials acceptable)
Beschrijving

PatientName,Last

Datatype

text

Patient First Name (initials acceptable)
Beschrijving

PatientName,First

Datatype

text

Patient Middle Name (initials acceptable)
Beschrijving

PatientName,Middle

Datatype

text

Form Administration
Beschrijving

Form Administration

Person Completing Form, Last Name
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Person Completing Form, First Name
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

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

AmendedDataInd

Datatype

text

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

Vital Status

Patient's Vital Status
Beschrijving

Patient'sVitalStatus

Datatype

text

Primary Cause of Death (check one)
Beschrijving

DeathReason

Datatype

text

Describe cause of death
Beschrijving

DeathReason,Specify

Datatype

text

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

DeathDate/LastContactDate

Datatype

date

Disease Follow-up Status
Beschrijving

Disease Follow-up Status

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

CancerFollow-upStatusInd

Datatype

text

Date of Last Clinical Assessment (MM DD YYYY)
Beschrijving

CancerFollow-upStatusDate

Datatype

date

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

ChestX-RayAssessmentDate

Datatype

date

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

Abdominal/PelvicCTAssessmentDate

Datatype

text

Notice Of Progression
Beschrijving

Notice Of Progression

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

ProgressionInd,LocalAdvanced

Datatype

text

Date of First Local Progression (MM DD YYYY)
Beschrijving

ProgressionDate,FirstLocal

Datatype

date

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

ProgressionSite,FirstLocal

Datatype

text

Other, specify
Beschrijving

ProgressionSite,FirstLocal,Other

Datatype

text

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

ProgressionInd,LocalNodes

Datatype

text

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

ProgressionDate,FirstLocalNode

Datatype

date

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

ProgressionSite,FirstLocalNode

Datatype

text

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

ProgressionInd,DistantMetastatic

Datatype

text

Date of First Distant Progression (MM DD YYYY)
Beschrijving

ProgressionDate,FirstDistant

Datatype

date

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

ProgressionSite,FirstDistant

Datatype

text

Distant nodes, specify
Beschrijving

LymphNodes,DistantLocation

Datatype

text

Other, specify
Beschrijving

Other,specify

Datatype

text

Other, specify
Beschrijving

Other,specify

Datatype

text

Notice Of New Primary
Beschrijving

Notice Of New Primary

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

NewPrimaryCancerInd

Datatype

text

Date of Diagnosis (MM DD YYYY)
Beschrijving

NewPrimaryCancerDate

Datatype

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.)
Beschrijving

NewPrimarySite

Datatype

text

Notice Of Long Term Toxicity
Beschrijving

Notice Of Long Term Toxicity

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

LateAdverseEventInd

Datatype

text

Late Adverse Event Term
Beschrijving

LateAdverseEventTerm

Datatype

text

Late Adverse Event Grade
Beschrijving

LateAdverseEventGrade

Datatype

text

Date of Onset of Long-Term Toxicity
Beschrijving

LateAdverseEventOnsetDate

Datatype

date

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

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

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

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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