ID

10189

Beschreibung

Southwest Oncology Group Registration Form (S0226) S0226 Anastrozole With or Without Fulvestrant as First-Line Therapy in Postmenopausal Women With Metastatic Breast Cancer NCT00075764 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C3225DE6-8BA0-26CF-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C3225DE6-8BA0-26CF-E034-0003BA12F5E7

Stichworte

Versionen (3)
  1. 26.08.12 26.08.12 -
  2. 24.04.15 24.04.15 - Martin Dugas
  3. 27.09.21 27.09.21 -
Hochgeladen am

24. April 2015

DOI

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Breast Cancer Registration SWOG S0226 NCT00075764

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    1. No Instruction available.
Header
Beschreibung

Header

Alias
UMLS CUI-1
C1320722
SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Assigned Treatment Arm
Beschreibung

AssignedTreatmentArm

Datentyp

text

Activation Date
Beschreibung

ActivationDate

Datentyp

text

Last Amended Date
Beschreibung

LastAmendedDate

Datentyp

text

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

Other Group Patient Number
Beschreibung

OtherGroupPatientNumber

Datentyp

text

Participating Group Protocol Number
Beschreibung

ParticipatingGroupProtocolNumber

Datentyp

text

Caller's SWOG Roster ID
Beschreibung

Caller'sSWOGRosterID

Datentyp

text

IRB Approval Date
Beschreibung

IRBApprovalDate

Datentyp

text

SWOG Investigator Number
Beschreibung

SWOGInvestigatorNumber

Datentyp

text

Other Group Investigator Number (OR)
Beschreibung

OtherGroupInvestigatorIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C25936
UMLS 2011AA ObjectClass-2
C0035173
NCI Thesaurus ObjectClass-3
C43359
UMLS 2011AA ObjectClass-3
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Investigator Name
Beschreibung

OtherGroupInvestigatorIdentifierName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C25936
UMLS 2011AA ObjectClass-2
C0035173
NCI Thesaurus ObjectClass-3
C43359
UMLS 2011AA ObjectClass-3
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
Other Group Institution Number
Beschreibung

OtherGroupTreatingInstitutionIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
NCI Thesaurus ObjectClass-3
C41206
UMLS 2011AA ObjectClass-3
C1272753
NCI Thesaurus ObjectClass-4
C43359
UMLS 2011AA ObjectClass-4
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Institution Name
Beschreibung

OtherGroupTreatingInstitutionIdentifierName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
NCI Thesaurus ObjectClass-3
C41206
UMLS 2011AA ObjectClass-3
C1272753
NCI Thesaurus ObjectClass-4
C43359
UMLS 2011AA ObjectClass-4
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain-2
C21541
UMLS 2011AA ValueDomain-2
C0018704
SWOG Treating Institution Number
Beschreibung

SWOGTreatingInstitutionNumber

Datentyp

text

Date HIPAA Authorization signed
Beschreibung

DateHIPAAAuthorizationsigned

Datentyp

text

Method of Payment
Beschreibung

MethodofPayment

Datentyp

text

Patient Social Security Number
Beschreibung

PatientSocialSecurityNumber

Datentyp

text

Patient's ZIP Code
Beschreibung

Patient'sZIPCode

Datentyp

text

Country of Residence
Beschreibung

CountryofResidence

Datentyp

text

Social Insurance Number
Beschreibung

SocialInsuranceNumber

Datentyp

text

Postal Code
Beschreibung

PostalCode

Datentyp

text

Patient data
Beschreibung

Patient data

Alias
UMLS CUI-1
C2707520
Patient's Date of Birth
Beschreibung

Patient'sDateofBirth

Datentyp

date

Alias
UMLS CUI-1
C0421451
Projected Start Date of Treatment
Beschreibung

ProjectedStartDateofTreatment

Datentyp

date

Alias
UMLS CUI-1
C3173309
Patient Gender
Beschreibung

Patient Gender

Datentyp

text

Alias
UMLS CUI-1
C0079399
Patient's Ethnicity
Beschreibung

Patient's Ethnicity

Datentyp

text

Alias
UMLS CUI-1
C0015031
Patient's Race
Beschreibung

Patient's Race

Datentyp

text

Alias
UMLS CUI-1
C0034510
Prior adjuvant tamoxifen therapy
Beschreibung

Prior adjuvant tamoxifen therapy

Datentyp

boolean

Consent
Beschreibung

Consent

Alias
UMLS CUI-1
C1511481
Date Informed Consent Signed
Beschreibung

DateInformedConsentSigned

Datentyp

date

Alias
UMLS CUI-1
C2985782
My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
Beschreibung

Mytissuemaybekeptforuseinresearchtolearnabout,prevent,treat,orcurecancer.

Datentyp

boolean

Alias
UMLS CUI-1
C0040300
UMLS CUI-2
C1516225
My tissue may be kept for research about other health problems
Beschreibung

Mytissuemaybekeptforresearchaboutotherhealthproblems

Datentyp

boolean

Alias
UMLS CUI-1
C0040300
UMLS CUI-2
C0035168
Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
Beschreibung

SomeonefromSouthwestOncologyGroupmaycontactmeinthefuturetoaskmetotakepartinmoreresearch

Datentyp

boolean

Alias
UMLS CUI-1
C0521104
UMLS CUI-2
C2051501
I agree to allow my study doctor, or someone approved by my study doctor, to contact me regard future research involving my participation in this study
Beschreibung

SouthwestOncologyGroupPatientResearchConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C25699
NCI Thesaurus Property
C15319
NCI Thesaurus Property-2
C25460
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0030705
UMLS CUI-2
C1519429
UMLS CUI-3
C1511481
UMLS CUI-4
C1512698
I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
Beschreibung

PatientBloodSpecimenAgentMetabolismConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C12434
NCI Thesaurus Property-2
C1708
NCI Thesaurus Property-3
C19157
NCI Thesaurus Property-4
C25460
NCI Thesaurus Property-5
C21198
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0521104
UMLS CUI-2
C0178913
UMLS CUI-3
C0935916
I agree to submit blood samples for the analysis of human epidermal growth factor receptor 2 (HER-2) protein to see if high levels will predict if I am less likely to respond to hormone therapy
Beschreibung

PatientBloodSpecimenEpidermalGrowthFactorReceptorConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C12434
NCI Thesaurus Property-2
C19157
NCI Thesaurus Property-3
C25460
NCI Thesaurus Property-4
C17068
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0521104
UMLS CUI-2
C0178913
UMLS CUI-3
C0034802
I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
Beschreibung

PatientBloodSpecimenGeneExpressionConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C12434
NCI Thesaurus Property-2
C19157
NCI Thesaurus Property-3
C25460
NCI Thesaurus Property-4
C16608
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0521104
UMLS CUI-2
C0178913
UMLS CUI-3
C0017262
I agree to submit a tissue specimen for the analysis of estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER-2) to see if certain levels will predict if I am likely to respond to hormone therapy
Beschreibung

PatientTissueSpecimenEpidermalGrowthFactorReceptorEstrogenReceptorConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C12801
NCI Thesaurus Property-2
C19157
NCI Thesaurus Property-3
C17069
NCI Thesaurus Property-4
C25460
NCI Thesaurus Property-5
C17068
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C1511481
UMLS CUI-2
C1292533
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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
AssignedTreatmentArm
Item
Assigned Treatment Arm
text
ActivationDate
Item
Activation Date
text
LastAmendedDate
Item
Last Amended Date
text
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
OtherGroupPatientNumber
Item
Other Group Patient Number
text
ParticipatingGroupProtocolNumber
Item
Participating Group Protocol Number
text
Caller'sSWOGRosterID
Item
Caller's SWOG Roster ID
text
IRBApprovalDate
Item
IRB Approval Date
text
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
OtherGroupInvestigatorIdentifierNumber
Item
Other Group Investigator Number (OR)
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25936 (NCI Thesaurus ObjectClass-2)
C0035173 (UMLS 2011AA ObjectClass-2)
C43359 (NCI Thesaurus ObjectClass-3)
C0441833 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
OtherGroupInvestigatorIdentifierName
Item
Other Group Investigator Name
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25936 (NCI Thesaurus ObjectClass-2)
C0035173 (UMLS 2011AA ObjectClass-2)
C43359 (NCI Thesaurus ObjectClass-3)
C0441833 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
OtherGroupTreatingInstitutionIdentifierNumber
Item
Other Group Institution Number
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C1272753 (UMLS 2011AA ObjectClass-3)
C43359 (NCI Thesaurus ObjectClass-4)
C0441833 (UMLS 2011AA ObjectClass-4)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
OtherGroupTreatingInstitutionIdentifierName
Item
Other Group Institution Name
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C1272753 (UMLS 2011AA ObjectClass-3)
C43359 (NCI Thesaurus ObjectClass-4)
C0441833 (UMLS 2011AA ObjectClass-4)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C0018704 (UMLS 2011AA ValueDomain-2)
SWOGTreatingInstitutionNumber
Item
SWOG Treating Institution Number
text
DateHIPAAAuthorizationsigned
Item
Date HIPAA Authorization signed
text
Item
Method of Payment
text
CL.10
Code List
Method of Payment
CL Item
Private (Private)
CL Item
Medicare (Medicare)
CL Item
Medicare and Private (Medicare and Private)
CL Item
Medicaid (Medicaid)
CL Item
Medicaid and Medicare (Medicaid and Medicare)
CL Item
No insurance (self-pay) (No insurance (self-pay))
CL Item
No insurance (no means) (No insurance (no means))
CL Item
Other, specify at registration (Other, specify at registration)
CL Item
unknown (unknown)
CL Item
Veterans Admin (Veterans Admin)
CL Item
Military (Military)
PatientSocialSecurityNumber
Item
Patient Social Security Number
text
Patient'sZIPCode
Item
Patient's ZIP Code
text
CountryofResidence
Item
Country of Residence
text
SocialInsuranceNumber
Item
Social Insurance Number
text
PostalCode
Item
Postal Code
text
Item Group
Patient data
C2707520 (UMLS CUI-1)
Birth date
Item
Patient's Date of Birth
date
C0421451 (UMLS CUI-1)
Treatment start date
Item
Projected Start Date of Treatment
date
C3173309 (UMLS CUI-1)
Item
Patient Gender
text
C0079399 (UMLS CUI-1)
CL.9
Code List
Patient Gender
CL Item
Female (Female)
C0015780 (UMLS CUI-1)
CL Item
Male (Male)
C0086582 (UMLS CUI-1)
Item
Patient's Ethnicity
text
C0015031 (UMLS CUI-1)
CL.11
Code List
Patient's Ethnicity
CL Item
Unknown (Unknown)
CL Item
No (not Spanish) (No (not Spanish))
CL Item
Yes, Mexican (Yes, Mexican)
CL Item
Yes, Puerto Rican (Yes, Puerto Rican)
CL Item
Yes, Cuban (Yes, Cuban)
CL Item
Yes, Central American (Yes, Central American)
CL Item
Yes, South American (Yes, South American)
CL Item
Yes, Other (Yes, Other)
CL Item
Yes, NOS (Yes, NOS)
Item
Patient's Race
text
C0034510 (UMLS CUI-1)
CL.12
Code List
Patient's Race
CL Item
White or Caucasian (White or Caucasian)
CL Item
Black or African American (Black or African American)
CL Item
Native Hawaiian or Other Pacific Islander (Native Hawaiian or Other Pacific Islander)
CL Item
Asian (Asian)
CL Item
American Indian or Alaska Native (American Indian or Alaska Native)
Prior adjuvant tamoxifen therapy
Item
Prior adjuvant tamoxifen therapy
boolean
Item Group
Consent
C1511481 (UMLS CUI-1)
Informed consent date
Item
Date Informed Consent Signed
date
C2985782 (UMLS CUI-1)
Tissue for cancer research
Item
My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
boolean
C0040300 (UMLS CUI-1)
C1516225 (UMLS CUI-2)
Tissue for research
Item
My tissue may be kept for research about other health problems
boolean
C0040300 (UMLS CUI-1)
C0035168 (UMLS CUI-2)
Permission for further contact
Item
Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
boolean
C0521104 (UMLS CUI-1)
C2051501 (UMLS CUI-2)
Permission for further contact regarding research
Item
I agree to allow my study doctor, or someone approved by my study doctor, to contact me regard future research involving my participation in this study
boolean
C16960 (NCI Thesaurus ObjectClass)
C25699 (NCI Thesaurus ObjectClass-2)
C15319 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0030705 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
C1511481 (UMLS CUI-3)
C1512698 (UMLS CUI-4)
Permission for blood sample fulvestrant
Item
I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
boolean
C16960 (NCI Thesaurus ObjectClass)
C12434 (NCI Thesaurus Property)
C1708 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus Property-3)
C25460 (NCI Thesaurus Property-4)
C21198 (NCI Thesaurus Property-5)
C38147 (NCI Thesaurus ValueDomain)
C0521104 (UMLS CUI-1)
C0178913 (UMLS CUI-2)
C0935916 (UMLS CUI-3)
Permission blood sample HER-2
Item
I agree to submit blood samples for the analysis of human epidermal growth factor receptor 2 (HER-2) protein to see if high levels will predict if I am less likely to respond to hormone therapy
boolean
C16960 (NCI Thesaurus ObjectClass)
C12434 (NCI Thesaurus Property)
C19157 (NCI Thesaurus Property-2)
C25460 (NCI Thesaurus Property-3)
C17068 (NCI Thesaurus Property-4)
C38147 (NCI Thesaurus ValueDomain)
C0521104 (UMLS CUI-1)
C0178913 (UMLS CUI-2)
C0034802 (UMLS CUI-3)
Permission blood sample gene expression
Item
I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
boolean
C16960 (NCI Thesaurus ObjectClass)
C12434 (NCI Thesaurus Property)
C19157 (NCI Thesaurus Property-2)
C25460 (NCI Thesaurus Property-3)
C16608 (NCI Thesaurus Property-4)
C38147 (NCI Thesaurus ValueDomain)
C0521104 (UMLS CUI-1)
C0178913 (UMLS CUI-2)
C0017262 (UMLS CUI-3)
consent tissue specimen
Item
I agree to submit a tissue specimen for the analysis of estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER-2) to see if certain levels will predict if I am likely to respond to hormone therapy
boolean
C16960 (NCI Thesaurus ObjectClass)
C12801 (NCI Thesaurus Property)
C19157 (NCI Thesaurus Property-2)
C17069 (NCI Thesaurus Property-3)
C25460 (NCI Thesaurus Property-4)
C17068 (NCI Thesaurus Property-5)
C38147 (NCI Thesaurus ValueDomain)
C1511481 (UMLS CUI-1)
C1292533 (UMLS CUI-2)
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