ID

9398

Description

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

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/5/15 7/5/15 -
Uploaded on

January 9, 2015

DOI

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License

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

English

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 forms  
Header
Description

Header

SWOG Patient ID
Description

SWOGPatientID

Data type

text

Most Recent SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Patient Initials (L, F, M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution / Affiliate
Description

InstitutionName

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Group Name (Groups other than SWOG)
Description

ParticipatingGroupName

Data type

text

Study No. (Groups other than SWOG)
Description

Particip.GroupProtocolNumber

Data type

float

Pt. ID (Groups other than SWOG)
Description

PatientStudyID,ParticipatingGroup

Data type

text

Unnamed2
Description

Unnamed2

Date of Death (month / day / year)
Description

DeathDate/LastContactDate

Data type

date

Causes Of Death
Description

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
Description

DeathReason

Data type

text

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

DeathReason

Data type

text

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

DeathReason

Data type

text

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

DeathReason

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Data type

text

If Primary Cause, Contributory or Possible, specify
Description

DeathReason,Specify

Data type

text

Autopsy done?
Description

AutopsyInd

Data type

text

Death information obtained from (select all that apply)
Description

DeathInformationSource

Data type

text

Other, specify
Description

Other,specify

Data type

text

Notes
Description

Notes

Comments
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group Notice Of Death
Description

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
Most Recent SWOG Study No.
text
Patient Initials
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus 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)
float
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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