ID

10439

Beschrijving

S0205 Registration Form S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11C9703-C8D4-1BF2-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11C9703-C8D4-1BF2-E034-080020C9C0E0

Trefwoorden

Versies (4)
  1. 19-09-12 19-09-12 -
  2. 02-06-15 02-06-15 -
  3. 03-06-15 03-06-15 -
  4. 20-09-21 20-09-21 -
Geüploaded op

2 juni 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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S0205 Registration Form

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
SWOG clinical trial administrative data
Beschrijving

SWOG clinical trial administrative data

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Assigned Treatment Arm
Beschrijving

TreatmentArmNumber

Datatype

text

Activation Date
Beschrijving

ProtocolActivationDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25405
UMLS 2011AA Property
C1515882
Last Amended Date
Beschrijving

FormCompletionDate,Amended

Datatype

date

Patient's Name
Beschrijving

Patient'sName

Datatype

text

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Treating Institution Number
Beschrijving

NCIInstitutionNumber

Datatype

text

Date Informed Consent Signed
Beschrijving

InformedConsentDateSigned

Datatype

date

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

SWOGInvestigatorNumber

Datatype

text

IRB Approval Date
Beschrijving

IRBApprovalDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Beschrijving

ProjectedTreatmentBeginDate

Datatype

date

Patient demographics
Beschrijving

Patient demographics

Patient's Date of Birth
Beschrijving

PatientBirthDate

Datatype

date

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

PatientGender

Datatype

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
Beschrijving

PaymentMethod

Datatype

text

Patient's Ethnicity
Beschrijving

Patient'sEthnicity

Datatype

text

Patient's Race (select all that apply)
Beschrijving

PatientRace

Datatype

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Other, specify (If a U.S. resident)
Beschrijving

Other,specify

Datatype

text

Social Insurance Number
Beschrijving

PatientSocialSecurityNumber

Datatype

float

Patient's ZIP Code
Beschrijving

PatientAddress,PostalCode

Datatype

float

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

PatientAddress,Country

Datatype

text

Postal Code
Beschrijving

AddressPostalCode

Datatype

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
Stratification Factors
Beschrijving

StratificationFactors

Datatype

text

Disease status
Beschrijving

Diseasestatus

Datatype

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Metathesaurus Property
C0449438
Zubrod Performance Status
Beschrijving

PerformanceStatus

Datatype

text

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

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datatype

boolean

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

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datatype

boolean

Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
Beschrijving

PatientInitialConsent,Specimen,ContactInd

Datatype

boolean

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For S0205 Registration Form
Beschrijving

Ccrr Module For S0205 Registration Form

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
ProtocolActivationDate
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25405 (NCI Thesaurus Property)
C1515882 (UMLS 2011AA Property)
FormCompletionDate,Amended
Item
Last Amended Date
date
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
NCIInstitutionNumber
Item
SWOG Treating Institution Number
text
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
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
date
Item Group
Patient demographics
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, speicfy at registration (Other, speicfy 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
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (not Spanish) (No (not Spanish))
CL Item
Yes, Mexican (Yes, Mexican)
CL Item
Yes, Puerto Rican (Yes, Puerto Rican)
CL Item
Yes, Cuban (Yes, Cuban)
CL Item
Yes, Central American (Yes, Central American)
CL Item
Yes, South American (Yes, South American)
CL Item
Yes, Other (Yes, Other)
CL Item
Yes, Nos (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
Other, specify (Other, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Other,specify
Item
Other, specify (If a U.S. resident)
text
PatientSocialSecurityNumber
Item
Social Insurance 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
AddressPostalCode
Item
Postal Code
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)
StratificationFactors
Item
Stratification Factors
text
Item
Disease status
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C0449438 (NCI Metathesaurus Property)
CL.8
Code List
Disease status
CL Item
Locally Advanced Unresectable (Locally advanced unresectable)
CL Item
Metastatic (Metastatic)
C14174 (NCI Thesaurus)
C0036525 (UMLS 2011AA)
Item
Zubrod Performance Status
text
CL.9
Code List
Zubrod Performance Status
CL Item
0 (0 to 1)
C0919414 (NCI Metathesaurus)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
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 research about other health problems (for example: causes of diabetes, Alzheimer's disease, 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 take part in more research.
boolean
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Registration Form
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