ID

849

Beschreibung

FORM 5M - MINIMAL FOLLOW-UP REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABF3BD71-F788-63E3-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABF3BD71-F788-63E3-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

26. August 2012

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Breast Cancer NCT00090974 Follow-Up - FORM 5M - MINIMAL FOLLOW-UP REPORT - 2064122v3.0

Englisch

USA Centres: Send CRFs to CTSU.

1 Formulare  
  1. StudyEvent: FORM 5M - MINIMAL FOLLOW-UP REPORT
    1. USA Centres: Send CRFs to CTSU.
Patient Information
Beschreibung

Patient Information

Patient Study ID, Coordinating Group
Beschreibung

PatientStudyID,CoordinatingGroup

Datentyp

text

Patient Initials (first - middle - last)
Beschreibung

PatientInitialsName

Datentyp

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
Patient Medical Record Number
Beschreibung

PatientMedicalRecordNumber

Datentyp

text

Investigator Name
Beschreibung

InvestigatorName

Datentyp

text

Institution Name
Beschreibung

InstitutionName

Datentyp

text

Registered Investigator (NCI Investigator #)
Beschreibung

RegisteredInvestigator

Datentyp

text

Status
Beschreibung

Status

Date of Last Contact or Death (yyyy mmm dd)
Beschreibung

DeathDate/LastContactDate

Datentyp

date

Patient's Vital Status
Beschreibung

Patient'sVitalStatus

Datentyp

text

Primary Cause of Death
Beschreibung

PrimaryCauseofDeath

Datentyp

text

Due to other cause, describe primary cause of death
Beschreibung

DeathReason,Specify

Datentyp

text

Due to other cause, describe primary cause of death
Beschreibung

DeathReason,Specify

Datentyp

text

Has the patient been diagnosed with first local-regional recurrence? (since submission of the last follow-up form)
Beschreibung

ProgressionInd,FirstLocal-Regional

Datentyp

text

Date of First Local-Regional Progression (yyyy mmm dd)
Beschreibung

ProgressionDate,FirstLocal-Regional

Datentyp

date

Has the patient been diagnosed with first distant recurrence/progression?
Beschreibung

ProgressionInd,FirstDistant

Datentyp

text

Date of First Distant Progression (yyyy mmm dd)
Beschreibung

ProgressionDate,FirstDistant

Datentyp

date

Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
Beschreibung

Hasthepatientbeendiagnosedwithcontralateralbreastcancer?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
Beschreibung

ContralateralBreastCancerDiagnosisDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass
C25307
UMLS 2011AA ObjectClass
C0441988
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Other Malignancies Or Myelodysplastic Syndrome
Beschreibung

Other Malignancies Or Myelodysplastic Syndrome

Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Beschreibung

NewPrimaryCancerInd

Datentyp

text

Date of diagnosis (yyyy mmm dd)
Beschreibung

NewPrimaryCancerDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Malignancy Type
Beschreibung

MalignancyType

Datentyp

text

Site(s) of New Primary
Beschreibung

NewPrimarySite

Datentyp

text

Describe (new primary cancer or MDS)
Beschreibung

NewPrimaryDiagnosis

Datentyp

text

Unnamed1
Beschreibung

Unnamed1

Patient Study ID, Coordinating Group
Beschreibung

PatientStudyID,CoordinatingGroup

Datentyp

text

Patient Initials (first - middle - last)
Beschreibung

PatientInitialsName

Datentyp

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
Comments
Beschreibung

Comments

COMMENTS
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

Investigator Signature

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Beschreibung

PersonCompletingForm,LastName

Datentyp

text

Person Completing Form, First Name
Beschreibung

PersonCompletingForm,FirstName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Beschreibung

FormCompletionDate,Original

Datentyp

date

Ccrr Module For Form 5m - Minimal Follow-up Report
Beschreibung

Ccrr Module For Form 5m - Minimal Follow-up Report

Zum Seitenanfang zurückkehren

Ähnliche Modelle

USA Centres: Send CRFs to CTSU.

1 Formulare
  1. StudyEvent: FORM 5M - MINIMAL FOLLOW-UP REPORT
    1. USA Centres: Send CRFs to CTSU.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientInitialsName
Item
Patient Initials (first - middle - last)
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)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InvestigatorName
Item
Investigator Name
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death (yyyy mmm dd)
date
Item
Patient's Vital Status
text
CL.1
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary Cause of Death
text
CL.2
Code List
Primary Cause of Death
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Cardiovascular death (specify) (Cardiovascular death (specify))
CL Item
Due To Other Cause, Specify (Due to other cause, describe primary cause of death)
DeathReason,Specify
Item
Due to other cause, describe primary cause of death
text
DeathReason,Specify
Item
Due to other cause, describe primary cause of death
text
Item
Has the patient been diagnosed with first local-regional recurrence? (since submission of the last follow-up form)
text
CL.3
Code List
Has the patient been diagnosed with first local-regional recurrence? (since submission of the last follow-up form)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
ProgressionDate,FirstLocal-Regional
Item
Date of First Local-Regional Progression (yyyy mmm dd)
date
Item
Has the patient been diagnosed with first distant recurrence/progression?
text
CL.4
Code List
Has the patient been diagnosed with first distant recurrence/progression?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Date of First Distant Progression (yyyy mmm dd)
date
Item
Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.5
Code List
Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ContralateralBreastCancerDiagnosisDate
Item
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
date
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25307 (NCI Thesaurus ObjectClass)
C0441988 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Other Malignancies Or Myelodysplastic Syndrome
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
text
CL.6
Code List
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of diagnosis (yyyy mmm dd)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
MalignancyType
Item
Malignancy Type
text
NewPrimarySite
Item
Site(s) of New Primary
text
NewPrimaryDiagnosis
Item
Describe (new primary cancer or MDS)
text
Item Group
Unnamed1
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientInitialsName
Item
Patient Initials (first - middle - last)
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)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Form 5m - Minimal Follow-up Report
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video