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ID
6937
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
Mots-clés
Versions (2)
- 26/08/2012 26/08/2012 -
- 08/01/2015 08/01/2015 - Martin Dugas
Téléchargé le
8 janvier 2015
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
No Instruction available.
- StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
Similar models
No Instruction available.
- StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus 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)
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
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)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
Alive (Alive-NED)
CL Item
Alive (Alive with Disease)
CL Item
Dead (Dead)
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)
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
CancerFollow-upStatusInd
Item
Has the patient had a documented clinical assessment for this cancer?
boolean
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)
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)
C0011008 (UMLS 2011AA ValueDomain)
Abdominal/PelvicCTAssessmentDate
Item
Abdominal/Pelvic CT Assessment Date
text
ProgressionInd,LocalAdvanced
Item
Has the patient been diagnosed with a local recurrence that has not been previously reported?
boolean
ProgressionDate,FirstLocal
Item
Date of First Local Progression (MM DD YYYY)
date
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
ProgressionInd,LocalNodes
Item
Has the patient been diagnosed with a local-regional lymph node recurrence?
boolean
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 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)
ProgressionInd,DistantMetastatic
Item
Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
boolean
ProgressionDate,FirstDistant
Item
Date of First Distant Progression (MM DD YYYY)
date
CL Item
Bone (bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
C0262950 (UMLS 2011AA)
CL Item
Liver (liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
C0023884 (UMLS 2011AA)
CL Item
Lung (lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
C0024109 (UMLS 2011AA)
CL Item
Peritoneum (peritoneum)
CL Item
Pleura (pleura)
CL Item
Skin (skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
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
NewPrimaryCancerInd
Item
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
boolean
NewPrimaryCancerDate
Item
Date of Diagnosis (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA 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
Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
text
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)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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
Comments
Item
Comments
text