ID

834

Descrição

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

Palavras-chave

Versões (3)
  1. 26/08/2012 26/08/2012 -
  2. 24/04/2015 24/04/2015 - Martin Dugas
  3. 27/09/2021 27/09/2021 -
Transferido a

26 de agosto de 2012

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

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

Inglês

No Instruction available.

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

Unnamed1

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Assigned Treatment Arm
Descrição

AssignedTreatmentArm

Tipo de dados

text

Activation Date
Descrição

ActivationDate

Tipo de dados

text

Last Amended Date
Descrição

LastAmendedDate

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

Other Group Patient Number
Descrição

OtherGroupPatientNumber

Tipo de dados

text

Participating Group Protocol Number
Descrição

ParticipatingGroupProtocolNumber

Tipo de dados

text

Unnamed3
Descrição

Unnamed3

Unnamed4
Descrição

Unnamed4

Other Group Investigator Number (OR)
Descrição

OtherGroupInvestigatorIdentifierNumber

Tipo de dados

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
Descrição

OtherGroupInvestigatorIdentifierName

Tipo de dados

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
Descrição

OtherGroupTreatingInstitutionIdentifierNumber

Tipo de dados

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
Descrição

OtherGroupTreatingInstitutionIdentifierName

Tipo de dados

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
Descrição

SouthwestOncologyGroupPatientResearchConsentInd-2

Tipo de dados

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
Descrição

PatientBloodSpecimenAgentMetabolismConsentInd-2

Tipo de dados

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
Descrição

PatientBloodSpecimenEpidermalGrowthFactorReceptorConsentInd-2

Tipo de dados

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
Descrição

PatientBloodSpecimenGeneExpressionConsentInd-2

Tipo de dados

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
Descrição

PatientTissueSpecimenEpidermalGrowthFactorReceptorEstrogenReceptorConsentInd-2

Tipo de dados

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
Descrição

Caller'sSWOGRosterID

Tipo de dados

text

IRB Approval Date
Descrição

IRBApprovalDate

Tipo de dados

text

Projected Start Date of Treatment
Descrição

ProjectedStartDateofTreatment

Tipo de dados

text

Date Informed Consent Signed
Descrição

DateInformedConsentSigned

Tipo de dados

text

SWOG Investigator Number
Descrição

SWOGInvestigatorNumber

Tipo de dados

text

SWOG Treating Institution Number
Descrição

SWOGTreatingInstitutionNumber

Tipo de dados

text

Date HIPAA Authorization signed
Descrição

DateHIPAAAuthorizationsigned

Tipo de dados

text

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

Mytissuemaybekeptforuseinresearchtolearnabout,prevent,treat,orcurecancer.

Tipo de dados

text

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

Mytissuemaybekeptforresearchaboutotherhealthproblems

Tipo de dados

text

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

SomeonefromSouthwestOncologyGroupmaycontactmeinthefuturetoaskmetotakepartinmoreresearch

Tipo de dados

text

Unnamed5
Descrição

Unnamed5

Patient's Date of Birth
Descrição

Patient'sDateofBirth

Tipo de dados

text

Patient Gender
Descrição

PatientGender

Tipo de dados

text

Method of Payment
Descrição

MethodofPayment

Tipo de dados

text

Patient's Ethnicity
Descrição

Patient'sEthnicity

Tipo de dados

text

Patient's Race
Descrição

Patient'sRace

Tipo de dados

text

Patient Social Security Number
Descrição

PatientSocialSecurityNumber

Tipo de dados

text

Patient's ZIP Code
Descrição

Patient'sZIPCode

Tipo de dados

text

Country of Residence
Descrição

CountryofResidence

Tipo de dados

text

Social Insurance Number
Descrição

SocialInsuranceNumber

Tipo de dados

text

Postal Code
Descrição

PostalCode

Tipo de dados

text

Prior adjuvant tamoxifen therapy
Descrição

Prioradjuvanttamoxifentherapy

Tipo de dados

text

Voltar ao início da página

Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
CL.4
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)
CL.5
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)
CL.6
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)
CL.7
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)
CL.8
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
CL.1
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
CL.2
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
CL.3
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
CL.9
Code List
Patient Gender
CL Item
Female (Female)
CL Item
Male (Male)
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)
Item
Patient's Ethnicity
text
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
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)
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
CL.13
Code List
Prior adjuvant tamoxifen therapy
CL Item
no (no)
CL Item
yes (yes)
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

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