ID

44596

Beschrijving

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

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 24-04-15 24-04-15 - Martin Dugas
  3. 27-09-21 27-09-21 -
Geüploaded op

27 september 2021

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Breast Cancer Registration SWOG S0226 NCT00075764

Engels

No Instruction available.

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

Header

Alias
UMLS CUI-1
C1320722
SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Assigned Treatment Arm
Beschrijving

AssignedTreatmentArm

Datatype

text

Activation Date
Beschrijving

ActivationDate

Datatype

text

Last Amended Date
Beschrijving

LastAmendedDate

Datatype

text

Patient's Name
Beschrijving

Patient'sName

Datatype

text

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

Other Group Patient Number
Beschrijving

OtherGroupPatientNumber

Datatype

text

Participating Group Protocol Number
Beschrijving

ParticipatingGroupProtocolNumber

Datatype

text

Caller's SWOG Roster ID
Beschrijving

Caller'sSWOGRosterID

Datatype

text

IRB Approval Date
Beschrijving

IRBApprovalDate

Datatype

text

SWOG Investigator Number
Beschrijving

SWOGInvestigatorNumber

Datatype

text

Other Group Investigator Number (OR)
Beschrijving

OtherGroupInvestigatorIdentifierNumber

Datatype

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
Beschrijving

OtherGroupInvestigatorIdentifierName

Datatype

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
Beschrijving

OtherGroupTreatingInstitutionIdentifierNumber

Datatype

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
Beschrijving

OtherGroupTreatingInstitutionIdentifierName

Datatype

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
Beschrijving

SWOGTreatingInstitutionNumber

Datatype

text

Date HIPAA Authorization signed
Beschrijving

DateHIPAAAuthorizationsigned

Datatype

text

Method of Payment
Beschrijving

MethodofPayment

Datatype

text

Patient Social Security Number
Beschrijving

PatientSocialSecurityNumber

Datatype

text

Patient's ZIP Code
Beschrijving

Patient'sZIPCode

Datatype

text

Country of Residence
Beschrijving

CountryofResidence

Datatype

text

Social Insurance Number
Beschrijving

SocialInsuranceNumber

Datatype

text

Postal Code
Beschrijving

PostalCode

Datatype

text

Patient data
Beschrijving

Patient data

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

Patient'sDateofBirth

Datatype

date

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

ProjectedStartDateofTreatment

Datatype

date

Alias
UMLS CUI-1
C3173309
Patient Gender
Beschrijving

Patient Gender

Datatype

text

Alias
UMLS CUI-1
C0079399
Patient's Ethnicity
Beschrijving

Patient's Ethnicity

Datatype

text

Alias
UMLS CUI-1
C0015031
Patient's Race
Beschrijving

Patient's Race

Datatype

text

Alias
UMLS CUI-1
C0034510
Prior adjuvant tamoxifen therapy
Beschrijving

Prior adjuvant tamoxifen therapy

Datatype

boolean

Consent
Beschrijving

Consent

Alias
UMLS CUI-1
C1511481
Date Informed Consent Signed
Beschrijving

DateInformedConsentSigned

Datatype

date

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

Mytissuemaybekeptforuseinresearchtolearnabout,prevent,treat,orcurecancer.

Datatype

boolean

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

Mytissuemaybekeptforresearchaboutotherhealthproblems

Datatype

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
Beschrijving

SomeonefromSouthwestOncologyGroupmaycontactmeinthefuturetoaskmetotakepartinmoreresearch

Datatype

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
Beschrijving

SouthwestOncologyGroupPatientResearchConsentInd-2

Datatype

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
Beschrijving

PatientBloodSpecimenAgentMetabolismConsentInd-2

Datatype

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
Beschrijving

PatientBloodSpecimenEpidermalGrowthFactorReceptorConsentInd-2

Datatype

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
Beschrijving

PatientBloodSpecimenGeneExpressionConsentInd-2

Datatype

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
Beschrijving

PatientTissueSpecimenEpidermalGrowthFactorReceptorEstrogenReceptorConsentInd-2

Datatype

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
Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
C0086287 (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)
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial