ID
9072
Description
SWOG S1201 Registration Worksheet Form Combination Chemotherapy in Treating Patients With Advanced or Metastatic Esophageal Cancer, Gastric Cancer, or Gastroesophageal Junction Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5907598-58E9-643E-E040-BB89AD4312F7
Lien
Mots-clés
Versions (3)
- 26/08/2012 26/08/2012 -
- 09/01/2015 09/01/2015 - Martin Dugas
- 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le
9 janvier 2015
DOI
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Licence
Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01498289 Registration - SWOG S1201 Registration Worksheet Form - 3341218v1.0
INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.
- StudyEvent: SWOG S1201 Registration Worksheet Form
Description
Swog Patient Id
Description
PatientSouthwestOncologyGroupIdentifierStatus
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus Property-2
- C25699
- UMLS 2011AA Property-2
- C1519429
- NCI Thesaurus ValueDomain
- C25688
- UMLS 2011AA ValueDomain
- C0449438
Description
Trial subject ID SWOG
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C1519429
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25699
Description
Demography
Description
First Name
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C1443235
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25509
Description
PatientMiddleName
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus Property-2
- C25569
- UMLS 2011AA Property-2
- C0444598
Description
Last Name
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C1301584
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25551
Description
Unnamed2
Description
RegistrarSouthwestOncologyGroupIdentifierNumber
Type de données
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
Description
SouthwestOncologyGroupInvestigatorIdentifierNumber
Type de données
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
Description
SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
Type de données
float
Alias
- NCI Thesaurus ObjectClass
- C25699
- UMLS 2011AA ObjectClass
- C1519429
- NCI Thesaurus ObjectClass-2
- C25705
- UMLS 2011AA ObjectClass-2
- C1522326
- NCI Thesaurus ObjectClass-3
- C41206
- UMLS 2011AA ObjectClass-3
- C1272753
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
Description
Unnamed5
Description
InformedConsentFormSignedDate
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain-2
- C25367
- NCI Thesaurus ObjectClass
- C16468
- UMLS 2011AA ObjectClass
- C0009797
- NCI Thesaurus Property
- C25679
Description
HIPAA Approval Date
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0600593
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C2346844
- NCI Thesaurus Property
- C25425
Description
Treatment Begin Date
Type de données
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus ObjectClass-2
- C25631
- NCI Thesaurus Property
- C25431
- UMLS CUI-1
- C3173309
- NCI Thesaurus Property-2
- C25275
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25431
Description
Stratification Question
Description
NeoplasmAnatomicSiteStratificationCode
Type de données
float
Alias
- NCI Thesaurus Property
- C13717
- UMLS 2011AA Property
- C1515974
- NCI Thesaurus ValueDomain
- C25162
- UMLS 2011AA ValueDomain
- C0805701
- NCI Thesaurus ObjectClass
- C3262
- UMLS 2011AA ObjectClass
- C0027651
- NCI Thesaurus Property-2
- C25689
- UMLS 2011AA Property-2
- C1514983
Description
Unnamed4
Description
PersonSpecimenMalignantNeoplasmResearchConsentInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C15319
- NCI Thesaurus Property-2
- C9305
- UMLS 2011AA Property
- C0006826
- NCI Thesaurus Property-3
- C19157
- UMLS 2011AA Property-2
- C0370003
- NCI Thesaurus Property-4
- C25460
- UMLS 2011AA Property-3
- C1511481
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
PatientOtherDiseaseorDisorderClinicalStudyConsentInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C17649
- UMLS 2011AA Property
- C0205394
- NCI Thesaurus Property-2
- C2991
- UMLS 2011AA Property-2
- C0012634
- NCI Thesaurus Property-3
- C15206
- UMLS 2011AA Property-3
- C0008972
- NCI Thesaurus Property-4
- C25460
- UMLS 2011AA Property-4
- C1511481
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
Permission to contact Patient
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-1
- C1522577
- NCI Thesaurus Property
- C67527
- UMLS CUI-2
- C0521104
- NCI Thesaurus Property-2
- C25460
- NCI Thesaurus Property-3
- C16452
- NCI Thesaurus ValueDomain
- C38148
Description
SouthwestOncologyGroupPatientResearchConsentInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C25699
- UMLS 2011AA ObjectClass-2
- C1519429
- NCI Thesaurus Property
- C15319
- NCI Thesaurus Property-2
- C25460
- UMLS 2011AA Property
- C1511481
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
Unnamed 7
Description
SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus ObjectClass-2
- C25699
- UMLS 2011AA ObjectClass-2
- C1519429
- NCI Thesaurus Property
- C25646
- UMLS 2011AA Property
- C1514821
- NCI Thesaurus Property-2
- C25171
- UMLS 2011AA Property-2
- C0013893
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Similar models
INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.
- StudyEvent: SWOG S1201 Registration Worksheet Form
C0011008 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C64382 (NCI Thesaurus Property)
C1879547 (UMLS 2011AA Property)
C41200 (NCI Thesaurus Property-2)
C0680532 (UMLS 2011AA Property-2)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus Property-2)
C1519429 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C1443235 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25569 (NCI Thesaurus Property-2)
C0444598 (UMLS 2011AA Property-2)
C1301584 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
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)
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)
C1519429 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C1272753 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16468 (NCI Thesaurus ObjectClass)
C0009797 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)
C0600593 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2346844 (UMLS CUI-2)
C25425 (NCI Thesaurus Property)
C25631 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C1515974 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25689 (NCI Thesaurus Property-2)
C1514983 (UMLS 2011AA Property-2)
C0027361 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property-3)
C0370003 (UMLS 2011AA Property-2)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property-2)
C0012634 (UMLS 2011AA Property-2)
C15206 (NCI Thesaurus Property-3)
C0008972 (UMLS 2011AA Property-3)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C1522577 (UMLS CUI-1)
C67527 (NCI Thesaurus Property)
C0521104 (UMLS CUI-2)
C25460 (NCI Thesaurus Property-2)
C16452 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C25699 (NCI Thesaurus ObjectClass-2)
C1519429 (UMLS 2011AA ObjectClass-2)
C15319 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property-2)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C25699 (NCI Thesaurus ObjectClass-2)
C1519429 (UMLS 2011AA ObjectClass-2)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
C25171 (NCI Thesaurus Property-2)
C0013893 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)