ID

9457

Descrição

Chemotherapy Form (Form 25/26-CT) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD161F67-0591-4F92-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD161F67-0591-4F92-E034-0003BA12F5E7

Palavras-chave

  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00066703 Treatment - Chemotherapy Form (Form 25/26-CT) - 2167893v3.0

No Instruction available.

  1. StudyEvent: Chemotherapy Form (Form 25/26-CT)
    1. No Instruction available.
Ccrr Module For Chemotherapy Form (form 25/26-ct)
Descrição

Ccrr Module For Chemotherapy Form (form 25/26-ct)

IBCSG Patient ID
Descrição

PatientInternationalBreastCancerStudyGroupIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C25530
UMLS 2011AA Property-2
C1512890
Patient Initials
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth
Descrição

Patient Birth Date

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0421451
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus Property
C25155
Participating Center/Affiliate
Descrição

ParticipatingCenter/Affiliate

Tipo de dados

text

Center Code
Descrição

CenterCode

Tipo de dados

text

Did the patient complete chemotherapy?
Descrição

Didthepatientcompletechemotherapy?

Tipo de dados

text

Reason code, specify (reason treatment ended)
Descrição

Reasoncode,specify(reasontreatmentended)

Tipo de dados

text

adverse event, specify
Descrição

Adverseevent,specify

Tipo de dados

text

medical decision, specify
Descrição

Medicaldecision,specify

Tipo de dados

text

other, specify
Descrição

OffTreatmentReason,Other

Tipo de dados

text

Reasons chemotherapy was delayed or modified
Descrição

Reasonschemotherapywasdelayedormodified

Tipo de dados

text

other toxicity, specify
Descrição

othertoxicity,specify

Tipo de dados

text

reason other than toxicity, specify
Descrição

reasonotherthantoxicity,specify

Tipo de dados

text

Date of first dose of chemotherapy
Descrição

PriorChemotherapyBeginDate

Tipo de dados

date

Date of last dose of chemotherapy
Descrição

Dateoflastdoseofchemotherapy

Tipo de dados

text

Total number of cycles of the regimen of chemotherapy given
Descrição

TotalCourseNumber

Tipo de dados

float

Investigator Signature
Descrição

InvestigatorSignature

Tipo de dados

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Descrição

Date

Tipo de dados

text

Agent Name
Descrição

Agent

Tipo de dados

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Agent Dose
Descrição

AgentDoseLevelValue

Tipo de dados

text

Alias
NCI Thesaurus Property
C25488
UMLS 2011AA Property
C0178602
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus Property-2
C25554
UMLS 2011AA Property-2
C0441889
Route of Administration
Descrição

AgentAdminRoute

Tipo de dados

text

Schedule & Frequency
Descrição

Schedule&Frequency

Tipo de dados

text

Leukocytes CTCAE Grade
Descrição

CTCAdverseEventWBCGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Platelets CTCAE Grade
Descrição

CTCAdverseEventPlateletGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Hemoglobin CTCAE Grade
Descrição

CTCAdverseEventHemoglobinGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Mucositis/Stomatis CTCAE Grade
Descrição

CTCAdverseEventStomatitisGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Fatigue CTCAE Grade
Descrição

CTCAdverseEventFatigueGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Dizziness/lightheadedness CTCAE Grade
Descrição

CTCAdverseEventDizzinessGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Somnolence/Depressed level of consciousness CTCAE Grade
Descrição

CTCAdverseEventConsciousnessGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Memory impairment CTCAE Grade
Descrição

CTCAdverseEventMemoryGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Mood alternation-depression CTCAE Grade
Descrição

CTCAdverseEventDepressionGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Neuropathy-sensory CTCAE Grade
Descrição

CommonToxicityCriteriaAdverseEventPeripheralSensoryNeuropathyGrade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C49704
UMLS 2011AA ObjectClass
C1516728
NCI Thesaurus ValueDomain
C18000
UMLS 2011AA ValueDomain
C0919553
NCI Metathesaurus Property
C0151313
Did the patient have other Grade 3 or higher adverse event(s)?
Descrição

DidthepatienthaveotherGrade3orhigheradverseevent(s)?

Tipo de dados

boolean

If yes, specify other CTCAE terms not listed
Descrição

CTCAdverseEventTermSpecify

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C41331
UMLS 2011AA ObjectClass
C0877248
NCI Thesaurus Property
C25703
UMLS 2011AA Property
C1515273
CTCAE Grade
Descrição

CTC Adverse Event Grade

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C41331
UMLS CUI-1
C2985911
NCI Thesaurus Property
C25365

Similar models

No Instruction available.

  1. StudyEvent: Chemotherapy Form (Form 25/26-CT)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Ccrr Module For Chemotherapy Form (form 25/26-ct)
PatientInternationalBreastCancerStudyGroupIdentifierNumber
Item
IBCSG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25530 (NCI Thesaurus Property-2)
C1512890 (UMLS 2011AA Property-2)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient Birth Date
Item
Patient's Date of Birth
date
C25164 (NCI Thesaurus ValueDomain)
C0421451 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C25155 (NCI Thesaurus Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
CenterCode
Item
Center Code
text
Item
Did the patient complete chemotherapy?
text
Code List
Did the patient complete chemotherapy?
CL Item
No, Will Never Start (no, will never start)
CL Item
No, Started But Stopped Early (no, started but stopped early)
CL Item
Yes, Completed With Modifications Or Delays Of One Week Or More (yes, completed with modifications or delays of one week or more)
CL Item
Yes, Completed As Planned (yes, completed as planned)
Item
Reason code, specify (reason treatment ended)
text
Code List
Reason code, specify (reason treatment ended)
CL Item
Patient Refused (patient refused)
CL Item
Adverse Event (adverse event)
C41331 (NCI Thesaurus)
C0877248 (UMLS 2011AA)
CL Item
Medical Decision (medical decision)
CL Item
Recurrence (recurrence)
C3352 (NCI Thesaurus)
C0034897 (UMLS 2011AA)
CL Item
Death On Study (death on study)
CL Item
Error (error)
C0743559 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
Adverseevent,specify
Item
adverse event, specify
text
Medicaldecision,specify
Item
medical decision, specify
text
OffTreatmentReason,Other
Item
other, specify
text
Item
Reasons chemotherapy was delayed or modified
text
Code List
Reasons chemotherapy was delayed or modified
CL Item
Hematologic Toxicity (hematologic toxicity)
CL Item
Other Toxicity, Specify (other toxicity, specify)
CL Item
Reason Other Than Toxicity, Specify (reason other than toxicity, specify)
othertoxicity,specify
Item
other toxicity, specify
text
reasonotherthantoxicity,specify
Item
reason other than toxicity, specify
text
PriorChemotherapyBeginDate
Item
Date of first dose of chemotherapy
date
Dateoflastdoseofchemotherapy
Item
Date of last dose of chemotherapy
text
TotalCourseNumber
Item
Total number of cycles of the regimen of chemotherapy given
float
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
Date
Item
Date
text
Agent
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
AgentDoseLevelValue
Item
Agent Dose
text
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25554 (NCI Thesaurus Property-2)
C0441889 (UMLS 2011AA Property-2)
AgentAdminRoute
Item
Route of Administration
text
Schedule&Frequency
Item
Schedule & Frequency
text
CTCAdverseEventWBCGrade
Item
Leukocytes CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventPlateletGrade
Item
Platelets CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventHemoglobinGrade
Item
Hemoglobin CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventStomatitisGrade
Item
Mucositis/Stomatis CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventFatigueGrade
Item
Fatigue CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventDizzinessGrade
Item
Dizziness/lightheadedness CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventConsciousnessGrade
Item
Somnolence/Depressed level of consciousness CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventMemoryGrade
Item
Memory impairment CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CTCAdverseEventDepressionGrade
Item
Mood alternation-depression CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CommonToxicityCriteriaAdverseEventPeripheralSensoryNeuropathyGrade
Item
Neuropathy-sensory CTCAE Grade
float
C49704 (NCI Thesaurus ObjectClass)
C1516728 (UMLS 2011AA ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)
C0151313 (NCI Metathesaurus Property)
DidthepatienthaveotherGrade3orhigheradverseevent(s)?
Item
Did the patient have other Grade 3 or higher adverse event(s)?
boolean
CTCAdverseEventTermSpecify
Item
If yes, specify other CTCAE terms not listed
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25703 (NCI Thesaurus Property)
C1515273 (UMLS 2011AA Property)
CTC Adverse Event Grade
Item
CTCAE Grade
float
C41331 (NCI Thesaurus ObjectClass)
C2985911 (UMLS CUI-1)
C25365 (NCI Thesaurus Property)

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