ID
778
Description
NSABP B-35 Form ALERT Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0587E1D-38C6-3AA5-E034-080020C9C0E0
Link
Keywords
Versions (4)
- 8/26/12 8/26/12 -
- 7/8/15 7/8/15 -
- 7/8/15 7/8/15 -
- 9/20/21 9/20/21 -
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 Toxicity - NSABP B-35 Form ALERT - 2034153v3.0
Form ALERT Instructions: *Use NCI's Common Toxicity Criteria (CTC) Version 2.0 to assess the adverse event (AE). *Report any grade 3 unexpected AE, or any grade 4 AE, or any grade 5 AE (as listed below). *Complete and FAX this form with all available supporting documentation to the NSABP Biostatistical Center (412/624-1082) within 24 hours of learning about the AE. *Report the AE regardless of attribution (relationship) to protocol therapy (tamoxifen/anastrozole). *Do not fax this report to the NCI, FDA or HPFB.
Description
Unnamed2
Description
FormCompletionDate,Original
Data type
date
Description
PatientAdverseEventAssessmentAgeYearCount
Data type
double
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C20989
- UMLS 2011AA Property
- C0031809
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus ValueDomain
- C29848
- UMLS 2011AA ValueDomain
- C0439234
- NCI Thesaurus ValueDomain
- C25463
- UMLS 2011AA ValueDomain
- C0750480
Description
LocalInstitutionalReviewBoardAdverseEventNotificationInd-2
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25388
- UMLS 2011AA ObjectClass
- C1947913
- NCI Thesaurus ObjectClass
- C16741
- UMLS 2011AA ObjectClass
- C0086911
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus Property
- C25297
- UMLS 2011AA Property
- C0422202
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
NCIInstitutionNumber
Data type
text
Description
SpecifyTypeofAdverseEvent(AE)
Data type
text
Description
CTCAdverseEventTerm
Data type
text
Description
4-CharacterNSABPCode
Data type
text
Description
CTCAdverseEvent,InitialReportDate
Data type
date
Description
PatientHospitalizationInd-2
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25179
- UMLS 2011AA Property
- C0019993
Description
CTCAdverseEventAttributionCode
Data type
text
Description
TreatmentStartDate
Data type
date
Description
DateofMostRecentTreatment
Data type
text
Description
BrieflydescribetheAE
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
Similar models
Form ALERT Instructions: *Use NCI's Common Toxicity Criteria (CTC) Version 2.0 to assess the adverse event (AE). *Report any grade 3 unexpected AE, or any grade 4 AE, or any grade 5 AE (as listed below). *Complete and FAX this form with all available supporting documentation to the NSABP Biostatistical Center (412/624-1082) within 24 hours of learning about the AE. *Report the AE regardless of attribution (relationship) to protocol therapy (tamoxifen/anastrozole). *Do not fax this report to the NCI, FDA or HPFB.
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1527021 (UMLS 2011AA ValueDomain)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C41331 (NCI Thesaurus Property)
C0877248 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C1947913 (UMLS 2011AA ObjectClass)
C16741 (NCI Thesaurus ObjectClass)
C0086911 (UMLS 2011AA ObjectClass)
C41331 (NCI Thesaurus Property)
C0877248 (UMLS 2011AA Property)
C25297 (NCI Thesaurus Property)
C0422202 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25179 (NCI Thesaurus Property)
C0019993 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0445356 (UMLS 2011AA)
C1527021 (UMLS 2011AA ValueDomain)