ID

10193

Descrição

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

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 27/04/2015 27/04/2015 - Martin Dugas
Transferido a

27 de abril de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Leukemia Registration SWOG S0805 NCT00792948

Inglês

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 Formulários  
Header
Descrição

Header

Alias
UMLS CUI-1
C1320722
Activation Date
Descrição

ClinicalStudyProtocolAmendmentActivationDate

Tipo de dados

date

Unidades de medida
  • 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
Descrição

DataAmendedLastDate

Tipo de dados

date

Unidades de medida
  • 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
Descrição

RegistrationStepNumber

Tipo de dados

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
Descrição

PatientSouthwestOncologyGroupIdentifierNumber

Tipo de dados

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
Descrição

RegistrarSouthwestOncologyGroupIdentifierNumber

Tipo de dados

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
Descrição

SouthwestOncologyGroupInvestigatorIdentifierNumber

Tipo de dados

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
Descrição

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Tipo de dados

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
Descrição

TreatmentProjectedBeginDate

Tipo de dados

date

Unidades de medida
  • 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
Descrição

TransplantationFacilityIdentifierName

Tipo de dados

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
Descrição

Approved Rt Facility

RT Start Date
Descrição

RTBeginDate

Tipo de dados

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
Descrição

InstitutionRadiationTherapyAdministrationName

Tipo de dados

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)
Descrição

RT Facility Number (SWOG institutions only)

Tipo de dados

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
Descrição

ReviewingRadiologistName

Tipo de dados

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
Descrição

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
Descrição

SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

Tipo de dados

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
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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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
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