ID

834

Beschreibung

Southwest Oncology Group Registration Form (S0226) S0226 Anastrozole With or Without Fulvestrant as First-Line Therapy in Postmenopausal Women With Metastatic Breast Cancer 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

Stichworte

  1. 26.08.12 26.08.12 -
  2. 24.04.15 24.04.15 - Martin Dugas
  3. 27.09.21 27.09.21 -
Hochgeladen am

26. August 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00075764 Registration - Southwest Oncology Group Registration Form (S0226) - 2173948v3.0

No Instruction available.

  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Assigned Treatment Arm
Beschreibung

AssignedTreatmentArm

Datentyp

text

Activation Date
Beschreibung

ActivationDate

Datentyp

text

Last Amended Date
Beschreibung

LastAmendedDate

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

Other Group Patient Number
Beschreibung

OtherGroupPatientNumber

Datentyp

text

Participating Group Protocol Number
Beschreibung

ParticipatingGroupProtocolNumber

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Unnamed4
Beschreibung

Unnamed4

Other Group Investigator Number (OR)
Beschreibung

OtherGroupInvestigatorIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C25936
UMLS 2011AA ObjectClass
C0035173
NCI Thesaurus ObjectClass
C43359
UMLS 2011AA ObjectClass
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Investigator Name
Beschreibung

OtherGroupInvestigatorIdentifierName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C25936
UMLS 2011AA ObjectClass
C0035173
NCI Thesaurus ObjectClass
C43359
UMLS 2011AA ObjectClass
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
Other Group Institution Number
Beschreibung

OtherGroupTreatingInstitutionIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
NCI Thesaurus ObjectClass
C41206
UMLS 2011AA ObjectClass
C1272753
NCI Thesaurus ObjectClass
C43359
UMLS 2011AA ObjectClass
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Institution Name
Beschreibung

OtherGroupTreatingInstitutionIdentifierName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
NCI Thesaurus ObjectClass
C41206
UMLS 2011AA ObjectClass
C1272753
NCI Thesaurus ObjectClass
C43359
UMLS 2011AA ObjectClass
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
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
Beschreibung

SouthwestOncologyGroupPatientResearchConsentInd-2

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C25699
UMLS 2011AA ObjectClass
C1519429
NCI Thesaurus Property
C15319
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
Beschreibung

PatientBloodSpecimenAgentMetabolismConsentInd-2

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property
C1708
UMLS 2011AA Property
C0450442
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus Property
C21198
UMLS 2011AA Property
C0025519
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
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
Beschreibung

PatientBloodSpecimenEpidermalGrowthFactorReceptorConsentInd-2

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus Property
C17068
UMLS 2011AA Property
C0034802
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
Beschreibung

PatientBloodSpecimenGeneExpressionConsentInd-2

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C12434
UMLS 2011AA Property
C0229664
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus Property
C16608
UMLS 2011AA Property
C0017262
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
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
Beschreibung

PatientTissueSpecimenEpidermalGrowthFactorReceptorEstrogenReceptorConsentInd-2

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C12801
UMLS 2011AA Property
C0040300
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C17069
UMLS 2011AA Property
C0034804
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus Property
C17068
UMLS 2011AA Property
C0034802
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Caller's SWOG Roster ID
Beschreibung

Caller'sSWOGRosterID

Datentyp

text

IRB Approval Date
Beschreibung

IRBApprovalDate

Datentyp

text

Projected Start Date of Treatment
Beschreibung

ProjectedStartDateofTreatment

Datentyp

text

Date Informed Consent Signed
Beschreibung

DateInformedConsentSigned

Datentyp

text

SWOG Investigator Number
Beschreibung

SWOGInvestigatorNumber

Datentyp

text

SWOG Treating Institution Number
Beschreibung

SWOGTreatingInstitutionNumber

Datentyp

text

Date HIPAA Authorization signed
Beschreibung

DateHIPAAAuthorizationsigned

Datentyp

text

My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
Beschreibung

Mytissuemaybekeptforuseinresearchtolearnabout,prevent,treat,orcurecancer.

Datentyp

text

My tissue may be kept for research about other health problems
Beschreibung

Mytissuemaybekeptforresearchaboutotherhealthproblems

Datentyp

text

Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
Beschreibung

SomeonefromSouthwestOncologyGroupmaycontactmeinthefuturetoaskmetotakepartinmoreresearch

Datentyp

text

Unnamed5
Beschreibung

Unnamed5

Patient's Date of Birth
Beschreibung

Patient'sDateofBirth

Datentyp

text

Patient Gender
Beschreibung

PatientGender

Datentyp

text

Method of Payment
Beschreibung

MethodofPayment

Datentyp

text

Patient's Ethnicity
Beschreibung

Patient'sEthnicity

Datentyp

text

Patient's Race
Beschreibung

Patient'sRace

Datentyp

text

Patient Social Security Number
Beschreibung

PatientSocialSecurityNumber

Datentyp

text

Patient's ZIP Code
Beschreibung

Patient'sZIPCode

Datentyp

text

Country of Residence
Beschreibung

CountryofResidence

Datentyp

text

Social Insurance Number
Beschreibung

SocialInsuranceNumber

Datentyp

text

Postal Code
Beschreibung

PostalCode

Datentyp

text

Prior adjuvant tamoxifen therapy
Beschreibung

Prioradjuvanttamoxifentherapy

Datentyp

text

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    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
AssignedTreatmentArm
Item
Assigned Treatment Arm
text
ActivationDate
Item
Activation Date
text
LastAmendedDate
Item
Last Amended Date
text
Item Group
Unnamed2
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
Item Group
Unnamed3
Item Group
Unnamed4
OtherGroupInvestigatorIdentifierNumber
Item
Other Group Investigator Number (OR)
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25936 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus ObjectClass)
C0441833 (UMLS 2011AA ObjectClass)
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)
C0035173 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus ObjectClass)
C0441833 (UMLS 2011AA ObjectClass)
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)
C1522326 (UMLS 2011AA ObjectClass)
C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus ObjectClass)
C0441833 (UMLS 2011AA ObjectClass)
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)
C1522326 (UMLS 2011AA ObjectClass)
C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus ObjectClass)
C0441833 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
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
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
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
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C1708 (NCI Thesaurus Property)
C0450442 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C21198 (NCI Thesaurus Property)
C0025519 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C17068 (NCI Thesaurus Property)
C0034802 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
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
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C16608 (NCI Thesaurus Property)
C0017262 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12801 (NCI Thesaurus Property)
C0040300 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C17069 (NCI Thesaurus Property)
C0034804 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C17068 (NCI Thesaurus Property)
C0034802 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
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
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Caller'sSWOGRosterID
Item
Caller's SWOG Roster ID
text
IRBApprovalDate
Item
IRB Approval Date
text
ProjectedStartDateofTreatment
Item
Projected Start Date of Treatment
text
DateInformedConsentSigned
Item
Date Informed Consent Signed
text
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
SWOGTreatingInstitutionNumber
Item
SWOG Treating Institution Number
text
DateHIPAAAuthorizationsigned
Item
Date HIPAA Authorization signed
text
Item
My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
text
Code List
My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
CL Item
yes (yes)
CL Item
no (no)
Item
My tissue may be kept for research about other health problems
text
Code List
My tissue may be kept for research about other health problems
CL Item
yes (yes)
CL Item
no (no)
Item
Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
text
Code List
Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
CL Item
yes (yes)
CL Item
no (no)
Item Group
Unnamed5
Patient'sDateofBirth
Item
Patient's Date of Birth
text
Item
Patient Gender
text
Code List
Patient Gender
CL Item
Female (Female)
CL Item
Male (Male)
Item
Method of Payment
text
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)
Item
Patient's Ethnicity
text
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
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)
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
Prior adjuvant tamoxifen therapy
text
Code List
Prior adjuvant tamoxifen therapy
CL Item
no (no)
CL Item
yes (yes)

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