ID

754

Beschreibung

SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer 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

Stichworte

Versionen (4)
  1. 26.08.12 26.08.12 -
  2. 22.04.15 22.04.15 - Martin Dugas
  3. 20.09.21 20.09.21 -
  4. 17.11.21 17.11.21 -
Hochgeladen am

26. August 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00070564 Registration - SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM - 2050049v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Assigned Treatment Arm
Beschreibung

TreatmentArmNumber

Datentyp

text

Activation Date
Beschreibung

ProtocolActivationDate

Datentyp

date

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

ProtocolRevisedDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed2
Beschreibung

Unnamed2

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Unnamed4
Beschreibung

Unnamed4

Caller's SWOG Roster ID
Beschreibung

RegistrarSouthwestOncologyGroupIdentifierNumber

Datentyp

text

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

NCIInstitutionNumber

Datentyp

text

Date Informed Consent Signed
Beschreibung

InformedConsentDateSigned

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
SWOG Investigator Number
Beschreibung

SouthwestOncologyGroupInvestigatorIdentifierNumber

Datentyp

double

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
C17089
UMLS 2011AA ObjectClass
C0035173
IRB Approval Date
Beschreibung

IRBApprovalDate

Datentyp

date

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

ProjectedTreatmentBeginDate

Datentyp

date

Patient Consent For Specimen Use
Beschreibung

Patient Consent For Specimen Use

Patient's initial consent given for specimen use for research on the patient's cancer?
Beschreibung

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datentyp

text

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

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datentyp

text

Patient's initial consent given for further contact regarding specimen?
Beschreibung

PatientInitialConsent,Specimen,ContactInd

Datentyp

text

Unnamed5
Beschreibung

Unnamed5

Patient's Date of Birth
Beschreibung

PatientBirthDate

Datentyp

date

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

PatientGender

Datentyp

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)
Beschreibung

MethodofPayment

Datentyp

text

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

Patient'sEthnicity

Datentyp

text

Patient's Race (select all that apply)
Beschreibung

PatientRace

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Patient's Social Security Number
Beschreibung

PatientSocialSecurityNumber

Datentyp

double

Patient's ZIP Code
Beschreibung

PatientAddress,PostalCode

Datentyp

double

Country of Residence (if not USA)
Beschreibung

PatientAddress,Country

Datentyp

text

Postal Code
Beschreibung

AddressPostalCode

Datentyp

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
Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Ccrr Module For Southwest Oncology Group Registration Form
Beschreibung

Ccrr Module For Southwest Oncology Group Registration Form

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP REGISTRATION FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
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)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
Item Group
Unnamed3
Item Group
Unnamed4
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)
C1519429 (UMLS 2011AA Property)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
NCIInstitutionNumber
Item
SWOG Treating Institution Number
text
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SouthwestOncologyGroupInvestigatorIdentifierNumber
Item
SWOG Investigator Number
double
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)
C0035173 (UMLS 2011AA ObjectClass)
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 Consent For Specimen Use
Item
Patient's initial consent given for specimen use for research on the patient's cancer?
text
CL.1
Code List
Patient's initial consent given for specimen use for research on the patient's cancer?
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient's initial consent given for specimen use for research unrelated to the patient's cancer?
text
CL.2
Code List
Patient's initial consent given for specimen use for research unrelated to the patient's cancer?
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient's initial consent given for further contact regarding specimen?
text
CL.3
Code List
Patient's initial consent given for further contact regarding specimen?
CL Item
Null (Yes)
CL Item
Null (No)
Item Group
Unnamed5
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)
C0015780 (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
CL.6
Code List
Patient's Ethnicity (Ethnicity Spanish/Hispanic Origin codes)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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 (select all that apply)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.7
Code List
Patient's Race (select all that apply)
CL Item
White_cdus (White or Caucasian)
CL Item
Black_cdus (Black or African American)
CL Item
Pacific_islander_cdus (Native Hawaiian or Other Pacific Islander)
CL Item
Asian_cdus (Asian)
CL Item
Native_american_cdus (American Indian or Alaska Native)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientSocialSecurityNumber
Item
Patient's Social Security Number
double
PatientAddress,PostalCode
Item
Patient's ZIP Code
double
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
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group Registration Form
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