ID

703

Description

ECOG Second Primary Form (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC346EE2-C452-2587-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC346EE2-C452-2587-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 08/07/2015 08/07/2015 -
Téléchargé le

26 août 2012

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer Follow-Up - ECOG Second Primary Form (E2100) - 2070459v3.0

Anglais

Form No. 630

1 Formulaires  
  1. StudyEvent: ECOG Second Primary Form (E2100)
    1. Form No. 630
Unnamed1
Description

Unnamed1

Registration Step
Description

RegistrationStep

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Patient's Name
Description

Patient'sName

Type de données

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Type de données

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Type de données

text

ECOG Patient ID
Description

ECOGPatientID

Type de données

text

ECOG Patient ID
Description

ECOGPatientID

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Type de données

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Type de données

text

Unnamed2
Description

Unnamed2

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
Unnamed3
Description

Unnamed3

Date of Diagnosis of Second Primary Cancer (M D Y)
Description

DateofDiagnosisofSecondPrimaryCancer

Type de données

text

Site of Second Primary Cancer
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteText

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass
C25666
UMLS 2011AA ObjectClass
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property
C25421
UMLS 2011AA Property
C0002808
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Include information on histologic subtype(s). (Please attach copies of any corroborating pathology reports.)
Description

Includeinformationonhistologicsubtype(s).

Type de données

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Type de données

text

ECOG Patient ID
Description

ECOGPatientID

Type de données

text

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
Description

BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols

Type de données

text

Briefly describe treatment planned or given for the diagnosis of this second primary
Description

Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary

Type de données

text

Comments
Description

Comments

Comments
Description

Comments

Type de données

text

Investigator Signature
Description

InvestigatorSignature

Type de données

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

Date

Type de données

text

Ccrr Module For Ecog Second Primary Form (e2100)
Description

Ccrr Module For Ecog Second Primary Form (e2100)

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Similar models

Form No. 630

1 Formulaires
  1. StudyEvent: ECOG Second Primary Form (E2100)
    1. Form No. 630
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
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
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed3
DateofDiagnosisofSecondPrimaryCancer
Item
Date of Diagnosis of Second Primary Cancer (M D Y)
text
SecondPrimaryMalignantNeoplasmAnatomicSiteText
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass)
C0205436 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s). (Please attach copies of any corroborating pathology reports.)
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
text
Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary
Item
Briefly describe treatment planned or given for the diagnosis of this second primary
text
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Date
Item
Date
text
Item Group
Ccrr Module For Ecog Second Primary Form (e2100)
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