ID

43517

Description

SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer NCT00070564 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678842F-926F-5086-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678842F-926F-5086-E034-0003BA0B1A09

Keywords

Versions (4)
  1. 8/26/12 8/26/12 -
  2. 4/22/15 4/22/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
  4. 11/17/21 11/17/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer Registration SWOG NCT00070564

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM
    1. No Instruction available.
Header
Description

Header

Alias
UMLS CUI-1
C1320722
SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Assigned Treatment Arm
Description

TreatmentArmNumber

Data type

text

Activation Date
Description

ProtocolActivationDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25405
UMLS 2011AA Property
C1515882
Last Amended Date
Description

ProtocolRevisedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Patient's Name
Description

Patient'sName

Data type

text

SWOG Patient ID
Description

SWOGPatientID

Data type

text

Comments
Description

Comments

Data type

text

Caller's SWOG Roster ID
Description

RegistrarSouthwestOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C25699
UMLS 2011AA Property-2
C1519429
NCI Thesaurus ObjectClass
C25357
UMLS 2011AA ObjectClass
C0557514
SWOG Treating Institution Number
Description

NCIInstitutionNumber

Data type

text

SWOG Investigator Number
Description

SouthwestOncologyGroupInvestigatorIdentifierNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25699
UMLS 2011AA ObjectClass
C1519429
NCI Thesaurus ObjectClass-2
C17089
UMLS 2011AA ObjectClass-2
C0035173
IRB Approval Date
Description

IRBApprovalDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Description

ProjectedTreatmentBeginDate

Data type

date

Patient characteristics
Description

Patient characteristics

Alias
UMLS CUI-1
C0815172
Patient's Date of Birth
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient's Sex
Description

PatientGender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17357
UMLS 2011AA Property
C0079399
Method of Payment (Method of Payment codes)
Description

MethodofPayment

Data type

text

Patient's Ethnicity (Ethnicity Spanish/Hispanic Origin codes)
Description

Patient'sEthnicity

Data type

text

Alias
UMLS CUI-1
C0015031
Patient's Race (select all that apply)
Description

PatientRace

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
UMLS CUI-1
C0034510
Patient's Social Security Number
Description

PatientSocialSecurityNumber

Data type

float

Patient's ZIP Code
Description

PatientAddress,PostalCode

Data type

text

Alias
UMLS CUI-1
C0421454
Country of Residence (if not USA)
Description

PatientAddress,Country

Data type

text

Postal Code
Description

AddressPostalCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25407
UMLS 2011AA ObjectClass
C1442065
NCI Thesaurus Property
C25621
UMLS 2011AA Property
C1514254
Patient Consent For Specimen Use
Description

Patient Consent For Specimen Use

Alias
UMLS CUI-1
C1548894 C0370003
Date Informed Consent Signed
Description

InformedConsentDateSigned

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Patient's initial consent given for specimen use for research on the patient's cancer?
Description

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Data type

boolean

Patient's initial consent given for specimen use for research unrelated to the patient's cancer?
Description

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Data type

boolean

Alias
UMLS CUI-1
C1548894
UMLS CUI-2
C0370003
Patient's initial consent given for further contact regarding specimen?
Description

PatientInitialConsent,Specimen,ContactInd

Data type

boolean

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
TreatmentArmNumber
Item
Assigned Treatment Arm
text
ProtocolActivationDate
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25405 (NCI Thesaurus Property)
C1515882 (UMLS 2011AA Property)
ProtocolRevisedDate
Item
Last Amended Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
Comments
Item
Comments
text
RegistrarSouthwestOncologyGroupIdentifierNumber
Item
Caller's SWOG Roster ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus Property-2)
C1519429 (UMLS 2011AA Property-2)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
NCIInstitutionNumber
Item
SWOG Treating Institution Number
text
SouthwestOncologyGroupInvestigatorIdentifierNumber
Item
SWOG Investigator Number
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C0035173 (UMLS 2011AA ObjectClass-2)
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
Item Group
Patient characteristics
C0815172 (UMLS CUI-1)
PatientBirthDate
Item
Patient's Date of Birth
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
Patient's Sex
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
CL.4
Code List
Patient's Sex
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
Item
Method of Payment (Method of Payment codes)
text
CL.5
Code List
Method of Payment (Method of Payment codes)
CL Item
Private Insurance (Private)
CL Item
Medicare (Medicare)
CL Item
Medicare And Private Insurance (Medicare and Private)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Self Pay (No insurance (self-pay))
CL Item
No Means Of Payment (No insurance (no means))
CL Item
Other (Other)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Millitary Or Veterans Administration (Veterans Admin)
CL Item
Military (Military)
Item
Patient's Ethnicity (Ethnicity Spanish/Hispanic Origin codes)
text
C0015031 (UMLS CUI-1)
CL.6
Code List
Patient's Ethnicity (Ethnicity Spanish/Hispanic Origin codes)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS CUI-1)
CL Item
No (not Spanish) (No (not Spanish))
CL Item
Mexican (Yes, Mexican)
C3829110 (UMLS CUI-1)
CL Item
Puerto Rican (Yes, Puerto Rican)
C0034043 (UMLS CUI-1)
CL Item
Cuban (Yes, Cuban)
C1553379 (UMLS CUI-1)
CL Item
Central American (Yes, Central American)
C0238914 (UMLS CUI-1)
CL Item
South American (Yes, South American)
C0425359 (UMLS CUI-1)
CL Item
Other (Yes, Other)
C0205394 (UMLS CUI-1)
CL Item
NOS (Yes, NOS)
Item
Patient's Race (select all that apply)
integer
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS CUI-1)
CL.7
Code List
Patient's Race (select all that apply)
CL Item
White or Caucasian (1)
C0007457 (UMLS CUI-1)
CL Item
Black or African American (2)
C0005680 (UMLS CUI-1)
CL Item
Native Hawaiian or Other Pacific Islander (3)
C0337920 (UMLS CUI-1)
CL Item
Asian (4)
C0078988 (UMLS CUI-1)
CL Item
American Indian or Alaska Native (5)
C0683984 (UMLS CUI-1)
CL Item
Unknown (6)
C0439673 (UMLS CUI-1)
PatientSocialSecurityNumber
Item
Patient's Social Security Number
float
ZIP code
Item
Patient's ZIP Code
text
C0421454 (UMLS CUI-1)
PatientAddress,Country
Item
Country of Residence (if not USA)
text
AddressPostalCode
Item
Postal Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
Item Group
Patient Consent For Specimen Use
C1548894 C0370003 (UMLS CUI-1)
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Specimen use for cancer research
Item
Patient's initial consent given for specimen use for research on the patient's cancer?
boolean
Patient consent for specimen use
Item
Patient's initial consent given for specimen use for research unrelated to the patient's cancer?
boolean
C1548894 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
Permission for further contact
Item
Patient's initial consent given for further contact regarding specimen?
boolean
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