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Record details of prior radiation therapy related to the disease being studies by the protocol or when the details would be clinically significant for the evaluation of this study.

Prior Radiation Supplement eCRF

Field Name

Description / Instructions


Visit Date(m)

Enter the date the form was completed.

Note: If the information was obtained at multiple visits, please enter the date the form was completed.


Date of First Dose(m)

Enter the date of the first dose of the radiation therapy. Partial dates are acceptable when the day is not known.


Date of Last Dose

Enter the date of the last dose of the radiation therapy. Partial dates are acceptable when the day is not known. Leave it blank if the therapy is currently being received. “Ongoing’ will be reported to CTMS or CDS.


RT ReasonSelect the term to explain the reason for the use of radiotherapy in a patient.

Use pick list.

Radiation Type(m)

Select the type of radiation therapy, e.g.: "proton beam", "external beam" or "Palliative RT".

Use pick list.

Other, Specify

Enter an explanation when ‘Other, Specify’ is selected as a ‘Radiation Type’

100 Characters

RT SiteSelect named and more specified location in the body that received radiation therapy.

Use pick list.

RT Organ

Select named location with the central nervous system that received radiation therapy (RT).

Use pick list.

RT Location

Select named location in the body that received radiation therapy.

Use pick list.

Side of Body/ OrganSelect text term to identify the specified/detailed anatomic location of a malignant neoplasm that arises from or metastasize to structures within the cranium.

Use pick list.

Side DetailSelect specification relating to the side or laterality of an anatomic location.

Use pick list.

RT Field Site (Site 1, Site 2, Site 3)Select term to identify the type of field used in the delivery of radiation therapy to a patient (up to 3 terms). 

Use pick list.

Total Dose

State the total radiation dose the patient received during the treatment period. Leave this field as well as the Total Dose UOM blank if the radiation therapy is ongoing.

8 characters

Total Dose UOM

Select the radiation dose units of measurement (e.g. cGy or rad, or cSv or rem).

Use pick list.

Number of FractionsEnter the numeric value for the number of dose-portions or fractions of radiation therapy actually administered to a patient as treatment.4 digits

Best Response

Select the best response for the irradiated lesion. It applies to the type of therapy/intervation for which conventional response calls are appropriate. Leave this field blank if the radiation therapy is ongoing.
CR - Complete Response
PR - Partial Response
MR - Minimal/Marginal Response
SD - Stable Disease
PD - Progressive Disease
NE - Not Evaluable
NA - Not Assessed
UK - Unknown
NR - No Response

Use pick list.

NonResponse Therapy Type

Select the therapy type for which the conventional response calls are not appropriate.
AJ - Adjuvant Therapy
PA - Palliative Therapy
NJ - Neoadjuvant Therapy
PR - Prophylaxis

Use pick list.

Relapse DateEnter the calendar date of return of disease following radiation therapy with a period of improvement or complete remission.


Legend: (m) RDC mandatory






Date of First Dose is greater than Date of Last Dose.

Enter a Date of First Dose that is equal to or earlier than the Date of Last Dose.


Date of First Dose and Date of Last Dose are in the future.

Enter a date that is equal to or earlier than the current date.


Both Best Response and Nonresponse Therapy Type are present/absent.

One and only one fields should be entered.


Prior Radiation Type 'Other Specify' and 'Other, Specify' field are not present together.

Enter ‘Other Specify’ if ‘Other Specify’ is selected as Prior Radiation Type.



Field Name



Therapy Type

Derive Therapy Type Code based on matching Therapy Type

Last updated by Blackburn, Katie (NIH/NCI) [C] on Apr 18, 2017