ID

6937

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 26/08/12 26/08/12 -
  2. 08/01/15 08/01/15 - Martin Dugas
Caricato su

8 gennaio 2015

DOI

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Licenza

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

Inglese

No Instruction available.

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

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Descrizione

CoordinatingGroupProtocolNumber

Tipo di dati

text

Coordinating Group Code
Descrizione

CoordinatingGroupCode

Tipo di dati

text

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

Protocol Title

Tipo di dati

text

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

PatientStudyID,CoordinatingGroup

Tipo di dati

text

Patient Study ID, Participating Group
Descrizione

PatientStudyID,ParticipatingGroup

Tipo di dati

text

Participating Group Code
Descrizione

ParticipatingGroupCode

Tipo di dati

text

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

InstitutionName

Tipo di dati

text

Affiliate
Descrizione

AffiliateName

Tipo di dati

text

Patient Last Name (initials acceptable)
Descrizione

PatientName,Last

Tipo di dati

text

Patient First Name (initials acceptable)
Descrizione

PatientName,First

Tipo di dati

text

Patient Middle Name (initials acceptable)
Descrizione

PatientName,Middle

Tipo di dati

text

Form Administration
Descrizione

Form Administration

Person Completing Form, Last Name
Descrizione

PersonCompletingForm,LastName

Tipo di dati

text

Person Completing Form, First Name
Descrizione

PersonCompletingForm,FirstName

Tipo di dati

text

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

AmendedDataInd

Tipo di dati

boolean

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

Vital Status

Patient's Vital Status
Descrizione

Patient'sVitalStatus

Tipo di dati

text

Primary Cause of Death (check one)
Descrizione

DeathReason

Tipo di dati

text

Describe cause of death
Descrizione

DeathReason,Specify

Tipo di dati

text

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

DeathDate/LastContactDate

Tipo di dati

date

Disease Follow-up Status
Descrizione

Disease Follow-up Status

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

CancerFollow-upStatusInd

Tipo di dati

boolean

Date of Last Clinical Assessment (MM DD YYYY)
Descrizione

CancerFollow-upStatusDate

Tipo di dati

date

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

ChestX-RayAssessmentDate

Tipo di dati

date

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

Abdominal/PelvicCTAssessmentDate

Tipo di dati

text

Notice Of Progression
Descrizione

Notice Of Progression

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

ProgressionInd,LocalAdvanced

Tipo di dati

boolean

Date of First Local Progression (MM DD YYYY)
Descrizione

ProgressionDate,FirstLocal

Tipo di dati

date

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

ProgressionSite,FirstLocal

Tipo di dati

text

Other, specify
Descrizione

ProgressionSite,FirstLocal,Other

Tipo di dati

text

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

ProgressionInd,LocalNodes

Tipo di dati

boolean

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

ProgressionDate,FirstLocalNode

Tipo di dati

date

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

ProgressionSite,FirstLocalNode

Tipo di dati

text

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

ProgressionInd,DistantMetastatic

Tipo di dati

boolean

Date of First Distant Progression (MM DD YYYY)
Descrizione

ProgressionDate,FirstDistant

Tipo di dati

date

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

ProgressionSite,FirstDistant

Tipo di dati

text

Distant nodes, specify
Descrizione

LymphNodes,DistantLocation

Tipo di dati

text

Other, specify
Descrizione

Other,specify

Tipo di dati

text

Other, specify
Descrizione

Other,specify

Tipo di dati

text

Notice Of New Primary
Descrizione

Notice Of New Primary

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

NewPrimaryCancerInd

Tipo di dati

boolean

Date of Diagnosis (MM DD YYYY)
Descrizione

NewPrimaryCancerDate

Tipo di dati

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.)
Descrizione

NewPrimarySite

Tipo di dati

text

Notice Of Long Term Toxicity
Descrizione

Notice Of Long Term Toxicity

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

LateAdverseEventInd

Tipo di dati

text

Late Adverse Event Term
Descrizione

LateAdverseEventTerm

Tipo di dati

text

Late Adverse Event Grade
Descrizione

LateAdverseEventGrade

Tipo di dati

text

Date of Onset of Long-Term Toxicity
Descrizione

LateAdverseEventOnsetDate

Tipo di dati

date

Comments
Descrizione

Comments

Comments
Descrizione

Comments

Tipo di dati

text

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

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

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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