0 Ratings
ID

10193

Description

Southwest Oncology Group S0805 Registration Worksheet Form (Step 3) Combination Chemotherapy With or Without Donor Stem Cell Transplant in Treating Patients With Acute Lymphoblastic Leukemia NCT00792948 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8FBEF46D-B6C8-4571-E040-BB89AD4363A1

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8FBEF46D-B6C8-4571-E040-BB89AD4363A1

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 4/27/15 4/27/15 - Martin Dugas
Uploaded on

April 27, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

  • Newest
  • Oldest
  • Popular
  • Newest
    • Newest
    • Oldest
    • Popular

    No comments

    In order to download data models you must be logged in. Please log in or register for free.

    Leukemia Registration SWOG S0805 NCT00792948

    English

    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.

    1 forms  
    Header
    Description

    Header

    Alias
    UMLS CUI-1
    C1320722
    Activation Date
    Description

    ClinicalStudyProtocolAmendmentActivationDate

    Data type

    date

    Measurement units
    • MM DD YYYY
    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C25320
    NCI Thesaurus Property
    C64382
    NCI Thesaurus Property-2
    C41200
    UMLS CUI-1
    C1515882
    MM DD YYYY
    Last Amended Date
    Description

    DataAmendedLastDate

    Data type

    date

    Measurement units
    • MM DD YYYY
    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    NCI Thesaurus ValueDomain-2
    C25551
    UMLS CUI-1
    C0680532
    UMLS CUI-2
    C0011008
    MM DD YYYY
    Registration Step
    Description

    RegistrationStepNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain-2
    C16154
    UMLS 2011AA ValueDomain-2
    C1704379
    SWOG Patient ID
    Description

    PatientSouthwestOncologyGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    UMLS CUI-1
    C2348585
    UMLS CUI-2
    C1519429
    Registrar's SWOG Roster ID Number
    Description

    RegistrarSouthwestOncologyGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    NCI Thesaurus ObjectClass
    C25357
    UMLS CUI-1
    C0557514
    SWOG Investigator Number
    Description

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Data type

    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
    SWOG Treating Institution Number
    Description

    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

    Data type

    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
    Projected Start Date of Treatment
    Description

    TreatmentProjectedBeginDate

    Data type

    date

    Measurement units
    • MM DD YYYY
    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C25631
    NCI Thesaurus Property
    C25431
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS CUI-1
    C3173309
    MM DD YYYY
    Which approved Transplant Center will be used
    Description

    TransplantationFacilityIdentifierName

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C15342
    UMLS 2011AA ObjectClass
    C0029216
    NCI Thesaurus ObjectClass-2
    C62574
    UMLS 2011AA ObjectClass-2
    C1547538
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Approved Rt Facility
    Description

    Approved Rt Facility

    RT Start Date
    Description

    RTBeginDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C25431
    UMLS 2011AA Property
    C0439659
    NCI Thesaurus Property-2
    C25275
    UMLS 2011AA Property-2
    C2745955
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    RT Facility Name
    Description

    InstitutionRadiationTherapyAdministrationName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C41206
    UMLS 2011AA ObjectClass
    C1272753
    NCI Thesaurus Property
    C15313
    UMLS 2011AA Property
    C1522449
    NCI Thesaurus Property-2
    C25409
    UMLS 2011AA Property-2
    C1533734
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain-2
    C21541
    UMLS 2011AA ValueDomain-2
    C0018704
    RT Facility Number (SWOG institutions only)
    Description

    RT Facility Number (SWOG institutions only)

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17059
    NCI Thesaurus ObjectClass-2
    C37984
    UMLS CUI-1
    C0237753
    UMLS CUI-2
    C0600091
    UMLS CUI-3
    C0034599
    UMLS CUI-4
    C0022877
    RT Physician
    Description

    ReviewingRadiologistName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17824
    UMLS 2011AA ObjectClass
    C0260194
    Patient Eligibility
    Description

    Patient Eligibility

    Alias
    UMLS CUI-1
    C1302261
    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
    Description

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

    Data type

    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
    Back to the top of the page

    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.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    C1320722 (UMLS CUI-1)
    Clinicyl Study Activation Date
    Item
    Activation Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C64382 (NCI Thesaurus Property)
    C41200 (NCI Thesaurus Property-2)
    C1515882 (UMLS CUI-1)
    Last Amended Date
    Item
    Last Amended Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus ValueDomain-2)
    C0680532 (UMLS CUI-1)
    C0011008 (UMLS CUI-2)
    RegistrationStepNumber
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C16154 (NCI Thesaurus Property)
    C1704379 (UMLS 2011AA Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    C1704379 (UMLS 2011AA ValueDomain-2)
    SWOG Patient ID
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    C2348585 (UMLS CUI-1)
    C1519429 (UMLS CUI-2)
    Registrar ID
    Item
    Registrar's SWOG Roster ID Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS CUI-1)
    SWOG Investigator Number
    Item
    SWOG Investigator Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus ObjectClass)
    C17089 (NCI Thesaurus ObjectClass-2)
    C0237753 (UMLS CUI-1)
    C1519429 (UMLS CUI-2)
    SWOG Treating Institution Number
    Item
    SWOG Treating Institution Number
    text
    C25699 (NCI Thesaurus ObjectClass)
    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)
    Treatment Projected Begin Date
    Item
    Projected Start Date of Treatment
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25631 (NCI Thesaurus ObjectClass-2)
    C25431 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C3173309 (UMLS CUI-1)
    TransplantationFacilityIdentifierName
    Item
    Which approved Transplant Center will be used
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C15342 (NCI Thesaurus ObjectClass)
    C0029216 (UMLS 2011AA ObjectClass)
    C62574 (NCI Thesaurus ObjectClass-2)
    C1547538 (UMLS 2011AA ObjectClass-2)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    Item Group
    Approved Rt Facility
    RTBeginDate
    Item
    RT Start Date
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C25431 (NCI Thesaurus Property)
    C0439659 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property-2)
    C2745955 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    InstitutionRadiationTherapyAdministrationName
    Item
    RT Facility Name
    text
    C41206 (NCI Thesaurus ObjectClass)
    C1272753 (UMLS 2011AA ObjectClass)
    C15313 (NCI Thesaurus Property)
    C1522449 (UMLS 2011AA Property)
    C25409 (NCI Thesaurus Property-2)
    C1533734 (UMLS 2011AA Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    C0018704 (UMLS 2011AA ValueDomain-2)
    RadiologyLabIdentifierNumber
    Item
    RT Facility Number (SWOG institutions only)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    C17059 (NCI Thesaurus ObjectClass)
    C37984 (NCI Thesaurus ObjectClass-2)
    C0237753 (UMLS CUI-1)
    C0600091 (UMLS CUI-2)
    C0034599 (UMLS CUI-3)
    C0022877 (UMLS CUI-4)
    ReviewingRadiologistName
    Item
    RT Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17824 (NCI Thesaurus ObjectClass)
    C0260194 (UMLS 2011AA ObjectClass)
    Item Group
    Patient Eligibility
    C1302261 (UMLS CUI-1)
    patient eligible
    Item
    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C25646 (NCI Thesaurus Property)
    C25171 (NCI Thesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1302261 (UMLS CUI-1)
    Back to the top of the page 

    Help

    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