ID

795

Beschrijving

SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678BEDB-9FFF-50A6-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678BEDB-9FFF-50A6-E034-0003BA0B1A09

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 05-07-15 05-07-15 -
Geüploaded op

26 augustus 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00070564 Follow-Up - SOUTHWEST ONCOLOGY GROUP NOTICE OF DEATH - 2050160v3.0

Engels

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren  
Unnamed1
Beschrijving

Unnamed1

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

Most Recent SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Patient Initials (L, F, M)
Beschrijving

PatientInitialsName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Institution / Affiliate
Beschrijving

InstitutionName

Datatype

text

Physician
Beschrijving

RegisteredInvestigator

Datatype

text

Group Name (Groups other than SWOG)
Beschrijving

ParticipatingGroupName

Datatype

text

Study No. (Groups other than SWOG)
Beschrijving

Particip.GroupProtocolNumber

Datatype

double

Pt. ID (Groups other than SWOG)
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Date of Death (month / day / year)
Beschrijving

DeathDate/LastContactDate

Datatype

date

Causes Of Death
Beschrijving

Causes Of Death

If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
Beschrijving

DeathReason

Datatype

text

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

Non-cancer and non-treatment related causes (select one)
Beschrijving

DeathReason

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

If Primary Cause, Contributory or Possible, specify
Beschrijving

DeathReason,Specify

Datatype

text

Autopsy done?
Beschrijving

AutopsyInd

Datatype

text

Death information obtained from (select all that apply)
Beschrijving

DeathInformationSource

Datatype

text

Other, specify
Beschrijving

Other,specify

Datatype

text

Notes
Beschrijving

Notes

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For Southwest Oncology Group Notice Of Death
Beschrijving

Ccrr Module For Southwest Oncology Group Notice Of Death

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Similar models

Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
Most Recent SWOG Study No.
text
PatientInitialsName
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician
text
ParticipatingGroupName
Item
Group Name (Groups other than SWOG)
text
Particip.GroupProtocolNumber
Item
Study No. (Groups other than SWOG)
double
PatientStudyID,ParticipatingGroup
Item
Pt. ID (Groups other than SWOG)
text
Item Group
Unnamed2
DeathDate/LastContactDate
Item
Date of Death (month / day / year)
date
Item Group
Causes Of Death
Item
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
text
CL.2
Code List
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
CL Item
Cancer of most recent SWOG study, specify cancer (Cancer of most recent SWOG study, specify cancer)
CL Item
Cancer of other SWOG study, specify cancer (Cancer of other SWOG study, specify cancer)
CL Item
Other cancer, specify (Other cancer, specify)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No (No)
CL Item
Primary Cause (Primary Cause)
CL Item
Contributory (Contributory)
CL Item
Possible (Possible)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
DeathReason,Specify
Item
If Primary Cause, Contributory or Possible, specify
text
Item
Autopsy done?
text
CL.5
Code List
Autopsy done?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Death information obtained from (select all that apply)
text
CL.6
Code List
Death information obtained from (select all that apply)
CL Item
Autopsy Was The Source Of Information On The Patient's Death (Autopsy report)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Medical record / Death certificate)
CL Item
Clinical Evidence Was The Source Of Information On The Patient's Death (Physician)
CL Item
Relative or friend (Relative or friend)
CL Item
The Source Of Information On The Patient's Death Is Not On This List, Specify Other (Other, specify)
Other,specify
Item
Other, specify
text
Item Group
Notes
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group Notice Of Death
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