ID

6937

Descripción

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

Palabras clave

Versiones (2)
  1. 26/8/12 26/8/12 -
  2. 8/1/15 8/1/15 - Martin Dugas
Subido en

8 de enero de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

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

Inglés

No Instruction available.

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

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Descripción

CoordinatingGroupProtocolNumber

Tipo de datos

text

Coordinating Group Code
Descripción

CoordinatingGroupCode

Tipo de datos

text

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

Protocol Title

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
Patient Study ID, Coordinating Group
Descripción

PatientStudyID,CoordinatingGroup

Tipo de datos

text

Patient Study ID, Participating Group
Descripción

PatientStudyID,ParticipatingGroup

Tipo de datos

text

Participating Group Code
Descripción

ParticipatingGroupCode

Tipo de datos

text

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

InstitutionName

Tipo de datos

text

Affiliate
Descripción

AffiliateName

Tipo de datos

text

Patient Last Name (initials acceptable)
Descripción

PatientName,Last

Tipo de datos

text

Patient First Name (initials acceptable)
Descripción

PatientName,First

Tipo de datos

text

Patient Middle Name (initials acceptable)
Descripción

PatientName,Middle

Tipo de datos

text

Form Administration
Descripción

Form Administration

Person Completing Form, Last Name
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Person Completing Form, First Name
Descripción

PersonCompletingForm,FirstName

Tipo de datos

text

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

AmendedDataInd

Tipo de datos

boolean

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

Vital Status

Patient's Vital Status
Descripción

Patient'sVitalStatus

Tipo de datos

text

Primary Cause of Death (check one)
Descripción

DeathReason

Tipo de datos

text

Describe cause of death
Descripción

DeathReason,Specify

Tipo de datos

text

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

DeathDate/LastContactDate

Tipo de datos

date

Disease Follow-up Status
Descripción

Disease Follow-up Status

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

CancerFollow-upStatusInd

Tipo de datos

boolean

Date of Last Clinical Assessment (MM DD YYYY)
Descripción

CancerFollow-upStatusDate

Tipo de datos

date

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

ChestX-RayAssessmentDate

Tipo de datos

date

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

Abdominal/PelvicCTAssessmentDate

Tipo de datos

text

Notice Of Progression
Descripción

Notice Of Progression

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

ProgressionInd,LocalAdvanced

Tipo de datos

boolean

Date of First Local Progression (MM DD YYYY)
Descripción

ProgressionDate,FirstLocal

Tipo de datos

date

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

ProgressionSite,FirstLocal

Tipo de datos

text

Other, specify
Descripción

ProgressionSite,FirstLocal,Other

Tipo de datos

text

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

ProgressionInd,LocalNodes

Tipo de datos

boolean

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

ProgressionDate,FirstLocalNode

Tipo de datos

date

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

ProgressionSite,FirstLocalNode

Tipo de datos

text

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

ProgressionInd,DistantMetastatic

Tipo de datos

boolean

Date of First Distant Progression (MM DD YYYY)
Descripción

ProgressionDate,FirstDistant

Tipo de datos

date

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

ProgressionSite,FirstDistant

Tipo de datos

text

Distant nodes, specify
Descripción

LymphNodes,DistantLocation

Tipo de datos

text

Other, specify
Descripción

Other,specify

Tipo de datos

text

Other, specify
Descripción

Other,specify

Tipo de datos

text

Notice Of New Primary
Descripción

Notice Of New Primary

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

NewPrimaryCancerInd

Tipo de datos

boolean

Date of Diagnosis (MM DD YYYY)
Descripción

NewPrimaryCancerDate

Tipo de datos

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.)
Descripción

NewPrimarySite

Tipo de datos

text

Notice Of Long Term Toxicity
Descripción

Notice Of Long Term Toxicity

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

LateAdverseEventInd

Tipo de datos

text

Late Adverse Event Term
Descripción

LateAdverseEventTerm

Tipo de datos

text

Late Adverse Event Grade
Descripción

LateAdverseEventGrade

Tipo de datos

text

Date of Onset of Long-Term Toxicity
Descripción

LateAdverseEventOnsetDate

Tipo de datos

date

Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

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

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

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
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)
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)
AmendedDataInd
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
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
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)
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
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
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
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.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)
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
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
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)
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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