ID

795

Descrição

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

Palavras-chave

Versões (3)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 05/07/2015 05/07/2015 -
Transferido a

26 de agosto de 2012

DOI

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Licença

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

Inglês

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 Formulários  
Unnamed1
Descrição

Unnamed1

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

Most Recent SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Patient Initials (L, F, M)
Descrição

PatientInitialsName

Tipo de dados

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
Descrição

InstitutionName

Tipo de dados

text

Physician
Descrição

RegisteredInvestigator

Tipo de dados

text

Group Name (Groups other than SWOG)
Descrição

ParticipatingGroupName

Tipo de dados

text

Study No. (Groups other than SWOG)
Descrição

Particip.GroupProtocolNumber

Tipo de dados

double

Pt. ID (Groups other than SWOG)
Descrição

PatientStudyID,ParticipatingGroup

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

Date of Death (month / day / year)
Descrição

DeathDate/LastContactDate

Tipo de dados

date

Causes Of Death
Descrição

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
Descrição

DeathReason

Tipo de dados

text

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

DeathReason

Tipo de dados

text

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

DeathReason

Tipo de dados

text

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

DeathReason

Tipo de dados

text

If Primary Cause, Contributory or Possible, specify
Descrição

DeathReason,Specify

Tipo de dados

text

If Primary Cause, Contributory or Possible, specify
Descrição

DeathReason,Specify

Tipo de dados

text

If Primary Cause, Contributory or Possible, specify
Descrição

DeathReason,Specify

Tipo de dados

text

If Primary Cause, Contributory or Possible, specify
Descrição

DeathReason,Specify

Tipo de dados

text

If Primary Cause, Contributory or Possible, specify
Descrição

DeathReason,Specify

Tipo de dados

text

Autopsy done?
Descrição

AutopsyInd

Tipo de dados

text

Death information obtained from (select all that apply)
Descrição

DeathInformationSource

Tipo de dados

text

Other, specify
Descrição

Other,specify

Tipo de dados

text

Notes
Descrição

Notes

Comments
Descrição

Comments

Tipo de dados

text

Ccrr Module For Southwest Oncology Group Notice Of Death
Descrição

Ccrr Module For Southwest Oncology Group Notice Of Death

Voltar ao início da página

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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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