ID

11763

Beskrivning

Registration Worksheet - 2169258v3.0 CALGB 90104 Registration Worksheet Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B0241-438C-6AC6-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B0241-438C-6AC6-E034-0003BA12F5E7

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-07-30 2015-07-30 - Martin Dugas
Uppladdad den

30 juli 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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Registration Bladder Cancer CALGB 90104 NCT00014534

No Instruction available.

  1. StudyEvent: CALGB 90104 Registration Worksheet
    1. No Instruction available.
Initial Patient Consent For Specimen Use
Beskrivning

Initial Patient Consent For Specimen Use

Patient's Initial Consent given for specimen use for research on the patient's cancer?
Beskrivning

Patient's Initial Consent given for specimen use for research on the patient's cancer?

Datatyp

boolean

Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?
Beskrivning

Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?

Datatyp

boolean

Patient's Initial Consent given for further contact regarding specimen?
Beskrivning

Patient's Initial Consent given for further contact regarding specimen?

Datatyp

boolean

assigned CALGB patient ID
Beskrivning

assignedCALGBpatientID

Datatyp

text

Registration date
Beskrivning

Registration date

Datatyp

date

Alias
UMLS CUI-1-1
C2985881
Assigned Participating Group Patient ID
Beskrivning

AssignedParticipatingGroupPatientID

Datatyp

text

Registrar's Signature
Beskrivning

Registrar'sSignature

Datatyp

text

Ccrr Module For Calgb 90104 Registration Worksheet
Beskrivning

Ccrr Module For Calgb 90104 Registration Worksheet

Alias
UMLS CUI-1
C1514821
Institution Name
Beskrivning

InstitutionName

Datatyp

text

Affiliate Institution
Beskrivning

AffiliateInstitution

Datatyp

text

Physician of Record
Beskrivning

PhysicianofRecord

Datatyp

text

Participating Group Name
Beskrivning

ParticipatingGroupName

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

IRB Approval Date
Beskrivning

IRBApprovalDate

Datatyp

text

Date Informed Consent Signed
Beskrivning

DateInformedConsentSigned

Datatyp

text

Projected Treatment Start Date
Beskrivning

ProjectedTreatmentStartDate

Datatyp

text

HIPAA Authorization Date
Beskrivning

HIPAAAuthorizationDate

Datatyp

text

Responsible contact
Beskrivning

Responsiblecontact

Datatyp

text

phone
Beskrivning

phone

Datatyp

text

fax
Beskrivning

fax

Datatyp

text

Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Alias
UMLS CUI-1-1
C2986440
Patient Social Security Number
Beskrivning

PatientSocialSecurityNumber

Datatyp

text

Patient date of birth
Beskrivning

Patient date of birth

Datatyp

date

Måttenheter
  • DD.MM.YYYY
Alias
UMLS CUI-1-1
C0421451
DD.MM.YYYY
Patient Hospital No.
Beskrivning

PatientHospitalNo.

Datatyp

text

Gender
Beskrivning

Gender

Datatyp

text

Alias
UMLS CUI-1-1
C0079399
Race
Beskrivning

Race

Datatyp

text

Performance Status (ECOG/Zubrod)
Beskrivning

PerformanceStatus(ECOG/Zubrod)

Datatyp

text

Height
Beskrivning

Height

Datatyp

float

Måttenheter
  • cm
Alias
UMLS CUI-1-1
C0005890
cm
Body weight
Beskrivning

Body weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI-1-1
C0005910
kg
Body surface area
Beskrivning

Body surface area

Datatyp

float

Måttenheter
Alias
UMLS CUI-1-1
C0005902
Method of Payment
Beskrivning

MethodofPayment

Datatyp

text

Patient's zip code
Beskrivning

Patient'szipcode

Datatyp

text

Country of residence (if not USA)
Beskrivning

Countryofresidence(ifnotUSA)

Datatyp

text

T status
Beskrivning

Tstatus

Datatyp

text

Lymph node involvement
Beskrivning

Lymphnodeinvolvement

Datatyp

text

Similar models

No Instruction available.

  1. StudyEvent: CALGB 90104 Registration Worksheet
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Initial Patient Consent For Specimen Use
Consent for specimen use in cancer research
Item
Patient's Initial Consent given for specimen use for research on the patient's cancer?
boolean
Consent for specimen use in research
Item
Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?
boolean
Permission to contact patient
Item
Patient's Initial Consent given for further contact regarding specimen?
boolean
assignedCALGBpatientID
Item
assigned CALGB patient ID
text
Registration date
Item
Registration date
date
C2985881 (UMLS CUI-1-1)
AssignedParticipatingGroupPatientID
Item
Assigned Participating Group Patient ID
text
Registrar'sSignature
Item
Registrar's Signature
text
Item Group
Ccrr Module For Calgb 90104 Registration Worksheet
C1514821 (UMLS CUI-1)
InstitutionName
Item
Institution Name
text
AffiliateInstitution
Item
Affiliate Institution
text
PhysicianofRecord
Item
Physician of Record
text
ParticipatingGroupName
Item
Participating Group Name
text
CALGBPatientID
Item
CALGB Patient ID
text
IRBApprovalDate
Item
IRB Approval Date
text
DateInformedConsentSigned
Item
Date Informed Consent Signed
text
ProjectedTreatmentStartDate
Item
Projected Treatment Start Date
text
HIPAAAuthorizationDate
Item
HIPAA Authorization Date
text
Responsiblecontact
Item
Responsible contact
text
phone
Item
phone
text
fax
Item
fax
text
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI-1-1)
PatientSocialSecurityNumber
Item
Patient Social Security Number
text
Birth date
Item
Patient date of birth
date
C0421451 (UMLS CUI-1-1)
PatientHospitalNo.
Item
Patient Hospital No.
text
Item
Gender
text
C0079399 (UMLS CUI-1-1)
Code List
Gender
CL Item
Male (M)
CL Item
Female (F)
Item
Race
text
Code List
Race
CL Item
American Indian or Alaskan Native (American Indian or Alaskan Native)
CL Item
Asian (Asian)
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
Unknown (Unknown)
CL Item
White (White)
CL Item
Ethnicity (Ethnicity)
CL Item
Hispanic or Latino (Hispanic or Latino)
CL Item
Non-Hispanic (Non-Hispanic)
CL Item
Unknown (Unknown)
PerformanceStatus(ECOG/Zubrod)
Item
Performance Status (ECOG/Zubrod)
text
Height
Item
Height
float
C0005890 (UMLS CUI-1-1)
Weight
Item
Body weight
float
C0005910 (UMLS CUI-1-1)
BSA
Item
Body surface area
float
C0005902 (UMLS CUI-1-1)
Item
Method of Payment
text
Code List
Method of Payment
CL Item
medicaid (medicaid)
CL Item
medicare and private insurance (medicare and private insurance)
CL Item
other (other)
CL Item
self pay (no insurance) (self pay (no insurance))
CL Item
medicaid and medicare (medicaid and medicare)
CL Item
military (including Champus and Tricare) (military (including Champus and Tricare))
CL Item
private insurance (private insurance)
CL Item
unknown (unknown)
CL Item
medicare (medicare)
CL Item
no means of payment (no insurance) (no means of payment (no insurance))
CL Item
veterans administration sponsored (veterans administration sponsored)
Patient'szipcode
Item
Patient's zip code
text
Countryofresidence(ifnotUSA)
Item
Country of residence (if not USA)
text
Item
T status
text
Code List
T status
CL Item
T3 (T3)
CL Item
T4 (T4)
Item
Lymph node involvement
text
Code List
Lymph node involvement
CL Item
absent (absent)
CL Item
1 to 5 nodes invovled by tumor (1 to 5 nodes invovled by tumor)
CL Item
greater than or equal to 6 nodes involved by tumor (greater than or equal to 6 nodes involved by tumor)
CL Item
A (A)
CL Item
B (B)

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