ID

10372

Beschreibung

Southwest Oncology Group Registration Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF746B-17EF-3705-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF746B-17EF-3705-E034-080020C9C0E0

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 20.09.21 20.09.21 -
Hochgeladen am

28. Mai 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group Registration Form

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Southwest Oncology Group Registration Form
    1. No Instruction available.
SWOG clinical trial administrative data
Beschreibung

SWOG clinical trial administrative data

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Assigned Treatment Arm
Beschreibung

TreatmentArmNumber

Datentyp

text

Activation Date
Beschreibung

ActivationDate

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C64382
UMLS 2011AA Property
C1879547
NCI Thesaurus Property-2
C41200
UMLS 2011AA Property-2
C0680532
Last Amended Date
Beschreibung

DataAmendedLastDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
NCI Thesaurus ValueDomain-2
C25551
UMLS 2011AA ValueDomain-2
C1517741
Caller's SWOG Roster ID
Beschreibung

RegistrarSouthwestOncologyGroupIdentifierNumber

Datentyp

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
SWOG Treating Institution Number
Beschreibung

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Datentyp

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
Date Informed Consent Signed
Beschreibung

InformedConsentDateSigned

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
SWOG Investigator Number
Beschreibung

SouthwestOncologyGroupInvestigatorIdentifierNumber

Datentyp

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
IRB Approval Date
Beschreibung

IRBApprovalDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment (Patient Consent for Specimen Use)
Beschreibung

ProjectedTreatmentBeginDate

Datentyp

date

patient demographics
Beschreibung

patient demographics

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
Beschreibung

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datentyp

boolean

Patient's tissue may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's, and heart disease)
Beschreibung

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datentyp

boolean

Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to tak part in more research
Beschreibung

PatientInitialConsent,Specimen,ContactInd

Datentyp

boolean

Patient's Date of Birth
Beschreibung

PatientBirthDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient's Sex
Beschreibung

PatientGender

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17357
UMLS 2011AA Property
C0079399
Method of Payment
Beschreibung

PaymentMethod

Datentyp

text

Patient's Ethnicity
Beschreibung

Patient'sEthnicity

Datentyp

text

Patient's Race (select all that apply)
Beschreibung

PatientRace

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Other, specify (patient's race) (If a U.S. resident)
Beschreibung

Other,specify(patient'srace)

Datentyp

text

Patient's Social Security Number
Beschreibung

PatientSocialSecurityNumber

Datentyp

float

Patient's Zip Code
Beschreibung

PatientAddress,PostalCode

Datentyp

float

Country of Residence, if not USA (If a resident of Canada)
Beschreibung

PatientAddress,Country

Datentyp

text

Social Insurance Number
Beschreibung

PatientSocialInsuranceIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C62650
UMLS 2011AA ObjectClass-2
C0728831
NCI Thesaurus ObjectClass-3
C16745
UMLS 2011AA ObjectClass-3
C0021672
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Postal Code (Statification Factors)
Beschreibung

AddressPostalCode

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25407
UMLS 2011AA ObjectClass
C1442065
NCI Thesaurus Property
C25621
UMLS 2011AA Property
C1514254
Stage
Beschreibung

StageGrouping

Datentyp

text

LDH
Beschreibung

LDH

Datentyp

text

Notes
Beschreibung

Notes

Notes
Beschreibung

Comments

Datentyp

text

Ccrr Module For Southwest Oncology Group Registration Form
Beschreibung

Ccrr Module For Southwest Oncology Group Registration Form

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: Southwest Oncology Group Registration Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
SWOG clinical trial administrative data
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
TreatmentArmNumber
Item
Assigned Treatment Arm
text
ActivationDate
Item
Activation Date
text
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)
DataAmendedLastDate
Item
Last Amended Date
date
C25164 (NCI Thesaurus ValueDomain)
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)
RegistrarSouthwestOncologyGroupIdentifierNumber
Item
Caller's SWOG Roster ID
text
C25337 (NCI Thesaurus ValueDomain)
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)
SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
Item
SWOG Treating Institution Number
float
C25699 (NCI Thesaurus ObjectClass)
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)
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SouthwestOncologyGroupInvestigatorIdentifierNumber
Item
SWOG Investigator Number
float
C25337 (NCI Thesaurus ValueDomain)
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)
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment (Patient Consent for Specimen Use)
date
Item Group
patient demographics
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
PatientInitialConsent,Specimen,Patient'scancerresearchInd
Item
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
boolean
PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
Item
Patient's tissue may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's, and heart disease)
boolean
PatientInitialConsent,Specimen,ContactInd
Item
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to tak part in more research
boolean
PatientBirthDate
Item
Patient's Date of Birth
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
Patient's Sex
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
CL.4
Code List
Patient's Sex
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
Item
Method of Payment
text
CL.5
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)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Admin (Veterans Admin)
CL Item
Military (Military)
Item
Patient's Ethnicity
text
CL.6
Code List
Patient's Ethnicity
CL Item
Unknown2006635 (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No_not_spanish2006636 (No (not Spanish))
CL Item
Yes_mexican2006637 (Yes, Mexican)
CL Item
Yes_puerto_rican2006638 (Yes, Puerto Rican)
CL Item
Yes_cuban2006639 (Yes, Cuban)
CL Item
Yes_central_american2006640 (Yes, Central American)
CL Item
Yes_south_american2006641 (Yes, South American)
CL Item
Yes_other2006642 (Yes, Other)
CL Item
Yes_nos2006643 (Yes, NOS)
Item
Patient's Race (select all that apply)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.7
Code List
Patient's Race (select all that apply)
CL Item
White_cdus (White or Caucasian)
CL Item
Black_cdus (Black or African American)
CL Item
Pacific_islander_cdus (Native Hawaiian or Other Pacific Islander)
CL Item
Asian_cdus (Asian)
CL Item
Native_american_cdus (American Indian or Alaska Native)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Other, Specify (Other, Specify)
Other,specify(patient'srace)
Item
Other, specify (patient's race) (If a U.S. resident)
text
PatientSocialSecurityNumber
Item
Patient's Social Security Number
float
PatientAddress,PostalCode
Item
Patient's Zip Code
float
PatientAddress,Country
Item
Country of Residence, if not USA (If a resident of Canada)
text
PatientSocialInsuranceIdentifierNumber
Item
Social Insurance Number
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C62650 (NCI Thesaurus ObjectClass-2)
C0728831 (UMLS 2011AA ObjectClass-2)
C16745 (NCI Thesaurus ObjectClass-3)
C0021672 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
AddressPostalCode
Item
Postal Code (Statification Factors)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
Item
Stage
text
CL.8
Code List
Stage
CL Item
Iiib (not Recurrent) (IIIB)
CL Item
Iv (not Recurrent) (IV)
Item
LDH
text
CL.9
Code List
LDH
CL Item
</= Uln (</= ULN)
CL Item
> Uln (> ULN)
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For Southwest Oncology Group Registration Form
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