ID

42858

Beschreibung

RTOG-1010 A2 Registration Worksheet Form Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=903C5206-194A-6ECF-E040-BB89AD435F63

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=903C5206-194A-6ECF-E040-BB89AD435F63

Stichworte

  1. 18.12.14 18.12.14 - Martin Dugas
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 17.09.21 17.09.21 -
Hochgeladen am

17. September 2021

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG-1010 A2 Registration Worksheet Form - 3137821v1.0

No Instruction available.

  1. StudyEvent: RTOG-1010 A2 Registration Worksheet Form
    1. No Instruction available.
Module 1
Beschreibung

Module 1

Institutional person randomizing case
Beschreibung

RandomizationPersonName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C25196
UMLS 2011AA ObjectClass-2
C0034656
Is the patient going to receive protocol treatment
Beschreibung

ProtocolTreatmentAdministeredInd-3

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
If no, provide reason
Beschreibung

Reason treatment never started

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25594
UMLS CUI-1
C3539764
NCI Thesaurus Property-2
C25431
NCI Thesaurus Property-3
C25365
NCI Thesaurus ValueDomain
C25638
Participant Initials (FML)
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Verifying physician
Beschreibung

PhysicianPersonVerificationIdentifierName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C25741
UMLS 2011AA ObjectClass-2
C0031831
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C45513
UMLS 2011AA Property-2
C1711411
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
Patient ID
Beschreibung

Patient Study ID

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Calendar base date ([for step 2])
Beschreibung

TherapeuticProcedureCalendarGenerationDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C49236
UMLS 2011AA ObjectClass
C0087111
NCI Thesaurus Property
C19459
UMLS 2011AA Property
C1516147
NCI Thesaurus Property-2
C48151
UMLS 2011AA Property-2
C0079411
Randomization Date
Beschreibung

PatientRandomizationDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25196
UMLS 2011AA Property
C0034656
Has the Step 2 eligibility checklist been completed
Beschreibung

EligibilityDeterminationChecklistCompleteEligibilityInd-2

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus Property-2
C49073
UMLS 2011AA Property-2
C1707357
In the opinion of the investigator, is the patient eligible?
Beschreibung

Eligibility for trial

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1302261
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25171
Medical oncologist's name
Beschreibung

MedicalOncologistPersonIdentifierName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C17838
UMLS 2011AA ObjectClass-2
C1555767
Surgeon Name
Beschreibung

SurgeonName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C18071
UMLS 2011AA ObjectClass
C0582175
Patient has consented to take part in the Quality of Life Study
Beschreibung

PatientQualityofLifeConsentInd-2

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property-2
C25460
UMLS 2011AA Property-2
C1511481
If no, provide reason
Beschreibung

PersonQualityofLifeClinicalStudyRefuseConsentReason

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus Property-2
C49161
UMLS 2011AA Property-2
C1705116
NCI Thesaurus Property-3
C15206
UMLS 2011AA Property-3
C0008972
NCI Thesaurus Property-4
C25460
UMLS 2011AA Property-4
C1511481
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other reason, specify
Beschreibung

PersonQualityofLifeClinicalStudyRefuseConsentOtherSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus Property-2
C49161
UMLS 2011AA Property-2
C1705116
NCI Thesaurus Property-3
C15206
UMLS 2011AA Property-3
C0008972
NCI Thesaurus Property-4
C25460
UMLS 2011AA Property-4
C1511481
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
Other, specify
Beschreibung

PersonQualityofLifeClinicalStudyRefuseConsentSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus Property-2
C49161
UMLS 2011AA Property-2
C1705116
NCI Thesaurus Property-3
C15206
UMLS 2011AA Property-3
C0008972
NCI Thesaurus Property-4
C25460
UMLS 2011AA Property-4
C1511481
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Presence of adenopathy
Beschreibung

AbnormalLymphNodePresentIndicator

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C25401
UMLS 2011AA ObjectClass
C0205161
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
Other specify
Beschreibung

Reason treatment never started, specify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25594
UMLS CUI-1
C3539764
NCI Thesaurus Property-2
C25431
UMLS CUI-2
C1521902
NCI Thesaurus Property-3
C25365
NCI Thesaurus ValueDomain
C25685
Does not meet eligibility requirements, specify
Beschreibung

ScreeningRegistrationClinicalTrialIneligibilitySpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C48261
UMLS 2011AA ObjectClass
C1710032
NCI Thesaurus ObjectClass-2
C25646
UMLS 2011AA ObjectClass-2
C1514821
NCI Thesaurus Property
C15207
NCI Thesaurus Property-2
C40412
UMLS 2011AA Property
C1512714
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Other complicating disease, specify
Beschreibung

PatientObservationComplicatingDiseaseorDisorderEndReasonSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15722
UMLS 2011AA ObjectClass
C0700325
NCI Thesaurus Property
C2991
UMLS 2011AA Property
C0012634
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
NCI Thesaurus Property-3
C25496
UMLS 2011AA Property-3
C2746065
NCI Thesaurus Property-4
C25455
UMLS 2011AA Property-4
C1522701
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Is the patient HER2 positive
Beschreibung

PatientHER2/neuEligibilityDeterminationInd-2

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25171
UMLS 2011AA Property
C0013893
NCI Thesaurus Property-2
C17756
UMLS 2011AA Property-2
C0242957

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: RTOG-1010 A2 Registration Worksheet Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Module 1
RandomizationPersonName
Item
Institutional person randomizing case
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25196 (NCI Thesaurus ObjectClass-2)
C0034656 (UMLS 2011AA ObjectClass-2)
ProtocolTreatmentAdministeredInd-3
Item
Is the patient going to receive protocol treatment
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
If no, provide reason
text
C15368 (NCI Thesaurus ObjectClass)
C25594 (NCI Thesaurus Property)
C3539764 (UMLS CUI-1)
C25431 (NCI Thesaurus Property-2)
C25365 (NCI Thesaurus Property-3)
C25638 (NCI Thesaurus ValueDomain)
Code List
If no, provide reason
CL Item
Her2 Negative (HER2 negative)
CL Item
Does Not Meet Eligibility Requirements (Does not meet eligibility requirements)
CL Item
Physician Preference (Physician preference)
CL Item
Patient Refusal (Patient refusal)
CL Item
Other Complicating Disease (Other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Patient Initials
Item
Participant Initials (FML)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PhysicianPersonVerificationIdentifierName
Item
Verifying physician
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25741 (NCI Thesaurus ObjectClass-2)
C0031831 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C45513 (NCI Thesaurus Property-2)
C1711411 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
Patient Study ID
Item
Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
TherapeuticProcedureCalendarGenerationDate
Item
Calendar base date ([for step 2])
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C19459 (NCI Thesaurus Property)
C1516147 (UMLS 2011AA Property)
C48151 (NCI Thesaurus Property-2)
C0079411 (UMLS 2011AA Property-2)
PatientRandomizationDate
Item
Randomization Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25196 (NCI Thesaurus Property)
C0034656 (UMLS 2011AA Property)
EligibilityDeterminationChecklistCompleteEligibilityInd-2
Item
Has the Step 2 eligibility checklist been completed
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C49073 (NCI Thesaurus Property-2)
C1707357 (UMLS 2011AA Property-2)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
MedicalOncologistPersonIdentifierName
Item
Medical oncologist's name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C17838 (NCI Thesaurus ObjectClass-2)
C1555767 (UMLS 2011AA ObjectClass-2)
SurgeonName
Item
Surgeon Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C18071 (NCI Thesaurus ObjectClass)
C0582175 (UMLS 2011AA ObjectClass)
PatientQualityofLifeConsentInd-2
Item
Patient has consented to take part in the Quality of Life Study
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property-2)
C1511481 (UMLS 2011AA Property-2)
Item
If no, provide reason
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property-2)
C1705116 (UMLS 2011AA Property-2)
C15206 (NCI Thesaurus Property-3)
C0008972 (UMLS 2011AA Property-3)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-4)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
Code List
If no, provide reason
CL Item
Patient Refused Due To Illness (Patient refused due to illness)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
CL Item
Not Approved By Institutional Irb (Not approved by institutional IRB)
CL Item
Tool Not Available In Patient's Language (Tool not available in patient's language)
CL Item
Other, Specify (Other, specify)
PersonQualityofLifeClinicalStudyRefuseConsentOtherSpecify
Item
Other reason, specify
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property-2)
C1705116 (UMLS 2011AA Property-2)
C15206 (NCI Thesaurus Property-3)
C0008972 (UMLS 2011AA Property-3)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
PersonQualityofLifeClinicalStudyRefuseConsentSpecify
Item
Other, specify
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property-2)
C1705116 (UMLS 2011AA Property-2)
C15206 (NCI Thesaurus Property-3)
C0008972 (UMLS 2011AA Property-3)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Presence of adenopathy
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25401 (NCI Thesaurus ObjectClass)
C0205161 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
Code List
Presence of adenopathy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes Adenopathy, But Celiac Absent (Yes adenopathy, but celiac absent)
CL Item
Yes Adenopathy And Celiac Present <= 2 Cm (Yes adenopathy and celiac present <= 2 cm)
Reason treatment never started, specify
Item
Other specify
text
C15368 (NCI Thesaurus ObjectClass)
C25594 (NCI Thesaurus Property)
C3539764 (UMLS CUI-1)
C25431 (NCI Thesaurus Property-2)
C1521902 (UMLS CUI-2)
C25365 (NCI Thesaurus Property-3)
C25685 (NCI Thesaurus ValueDomain)
ScreeningRegistrationClinicalTrialIneligibilitySpecify
Item
Does not meet eligibility requirements, specify
text
C48261 (NCI Thesaurus ObjectClass)
C1710032 (UMLS 2011AA ObjectClass)
C25646 (NCI Thesaurus ObjectClass-2)
C1514821 (UMLS 2011AA ObjectClass-2)
C15207 (NCI Thesaurus Property)
C40412 (NCI Thesaurus Property-2)
C1512714 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientObservationComplicatingDiseaseorDisorderEndReasonSpecify
Item
Other complicating disease, specify
text
C15722 (NCI Thesaurus ObjectClass)
C0700325 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
C25496 (NCI Thesaurus Property-3)
C2746065 (UMLS 2011AA Property-3)
C25455 (NCI Thesaurus Property-4)
C1522701 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientHER2/neuEligibilityDeterminationInd-2
Item
Is the patient HER2 positive
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25171 (NCI Thesaurus Property)
C0013893 (UMLS 2011AA Property)
C17756 (NCI Thesaurus Property-2)
C0242957 (UMLS 2011AA Property-2)

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