ID
10192
Description
Southwest Oncology Group S0925 Registration Worksheet Form (Step 1) Bicalutamide and Goserelin or Leuprolide Acetate With or Without Cixutumumab in Treating Patients With Newly Diagnosed Metastatic Prostate Cancer NCT01120236 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=94470DE4-29D5-D339-E040-BB89AD4306AB
Lien
Mots-clés
Versions (3)
- 19/09/2012 19/09/2012 -
- 09/01/2015 09/01/2015 - Martin Dugas
- 25/04/2015 25/04/2015 - Martin Dugas
Téléchargé le
25 avril 2015
DOI
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Licence
Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer Registration SWOG S0925 NCT01120236
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: Southwest Oncology Group S0925 Registration Worksheet Form (Step 1)
Description
Swog Patient Id
Description
PatientSouthwestOncologyGroupIdentifierStatus
Type de données
integer
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25699
- NCI Thesaurus ValueDomain
- C25688
- UMLS CUI-1
- C1519429
- UMLS CUI-2
- C0600091
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
FOR SWOG INSTITUTIONS
Description
RegistrarSouthwestOncologyGroupIdentifierNumber
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- NCI Thesaurus Property
- C25364
- NCI Thesaurus Property-2
- C25699
- NCI Thesaurus ObjectClass
- C25357
- UMLS CUI-1
- C0557514
Description
SouthwestOncologyGroupInvestigatorIdentifierNumber
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ObjectClass
- C25699
- NCI Thesaurus ObjectClass-2
- C17089
- UMLS CUI-1
- C0237753
- UMLS CUI-2
- C1519429
Description
SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C25699
- NCI Thesaurus ObjectClass-2
- C25705
- NCI Thesaurus ObjectClass-3
- C41206
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C1519429
- UMLS CUI-2
- C1272753
- UMLS CUI-3
- C0600091
Description
PATIENT INFORMATION
Alias
- UMLS CUI-1
- C1955348
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
Auxiliary Question
Description
PatientLateInductionRegistrationInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25646
- NCI Thesaurus Property-2
- C61367
- NCI Thesaurus Property-3
- C64998
- NCI Thesaurus ValueDomain
- C38147
- UMLS CUI-1
- C1514821
- UMLS CUI-2
- C0205087
Description
Stratification Question
Description
PatientPSAStratificationCode
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25162
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C17525
- NCI Thesaurus Property-2
- C25689
- UMLS CUI-1
- C0138741
Description
PerformanceStatusAssessmentPerformanceStatusStratificationCode
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25162
- NCI Thesaurus Property
- C25367
- NCI Thesaurus ObjectClass
- C20641
- NCI Thesaurus ValueDomain-2
- C25689
- UMLS CUI-1
- C1518965
Description
Indicate how the patient answered the following questions on the consent form
Description
SouthwestOncologyGroupPatientSpecimenSpecialConsentIndicator
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus ObjectClass-2
- C25699
- NCI Thesaurus Property
- C19157
- NCI Thesaurus Property-2
- C25460
- NCI Thesaurus Property-3
- C25684
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1511481
- UMLS CUI-2
- C1292533
Description
SouthwestOncologyGroupPatientResearchConsentIndicator
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus ObjectClass-2
- C25699
- NCI Thesaurus Property
- C15319
- NCI Thesaurus Property-2
- C25460
- NCI Thesaurus ValueDomain
- C25180
Description
Patient Eligibility
Alias
- UMLS CUI-1
- C1302261
Description
SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus ObjectClass-2
- C25699
- NCI Thesaurus Property
- C25646
- NCI Thesaurus Property-2
- C25171
- NCI Thesaurus ValueDomain
- C38147
- UMLS CUI-1
- C1302261
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: Southwest Oncology Group S0925 Registration Worksheet Form (Step 1)
C25320 (NCI Thesaurus ObjectClass)
C64382 (NCI Thesaurus Property)
C41200 (NCI Thesaurus Property-2)
C1879547 (UMLS CUI-1)
C0011008 (UMLS CUI-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)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25688 (NCI Thesaurus ValueDomain)
C1519429 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
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)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS CUI-1)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C0237753 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
C25705 (NCI Thesaurus ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C1519429 (UMLS CUI-1)
C1272753 (UMLS CUI-2)
C0600091 (UMLS CUI-3)
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)
C25646 (NCI Thesaurus Property)
C61367 (NCI Thesaurus Property-2)
C64998 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C0205087 (UMLS CUI-2)
C16960 (NCI Thesaurus ObjectClass)
C17525 (NCI Thesaurus Property)
C25689 (NCI Thesaurus Property-2)
C0138741 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25689 (NCI Thesaurus ValueDomain-2)
C1518965 (UMLS CUI-1)
C25699 (NCI Thesaurus ObjectClass-2)
C19157 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property-2)
C25684 (NCI Thesaurus Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1511481 (UMLS CUI-1)
C1292533 (UMLS CUI-2)
C25699 (NCI Thesaurus ObjectClass-2)
C15319 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property-2)
C25180 (NCI Thesaurus ValueDomain)
C25699 (NCI Thesaurus ObjectClass-2)
C25646 (NCI Thesaurus Property)
C25171 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)