ID

11602

Description

S1011 Registration Worksheet Step 2 (#8470) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9386BABC-0E79-AC8D-E040-BB89AD4309BA

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9386BABC-0E79-AC8D-E040-BB89AD4309BA

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 7/8/15 7/8/15 -
Uploaded on

July 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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S1011 Registration Worksheet Step 2 (#8470)

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 module
Description

Header module

Activation Date (MM DD YYYY)
Description

Activation Date

Data type

date

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

Data Amended Last Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
NCI Thesaurus ValueDomain-2
C25551
UMLS CUI-1
C0011008
UMLS CUI-2
C1517741
Registration Step
Description

Registration status

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25646
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
UMLS CUI-1
C0585727
Swog Patient Id
Description

Swog Patient Id

SWOG Patient ID
Description

SWOG Patient ID

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
UMLS CUI-1
C1519429
UMLS CUI-2
C3259154
Registrar's SWOG Roster ID Number
Description

Registrar's SWOG Roster ID Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
NCI Thesaurus ObjectClass
C25357
UMLS CUI-1
C0600091
UMLS CUI-2
C1519429
SWOG Investigator Number
Description

SWOG Investigator Number

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25699
NCI Thesaurus ObjectClass-2
C17089
UMLS CUI-1
C0600091
UMLS CUI-2
C1519429
SWOG Treating Institution Number
Description

SWOG Treating Institution Number

Data type

float

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
C1522326
UMLS CUI-3
C0600091
Stratification Questions
Description

Stratification Questions

Neoadjuvant chemotherapy
Description

Chemotherapy basis

Data type

text

Alias
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C15632
NCI Thesaurus Property-2
C15665
NCI Thesaurus Property-3
C25689
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C0600558
UMLS CUI-2
C3665472
Clinical stage
Description

Clinical statge

Data type

text

Alias
NCI Thesaurus ObjectClass
C15206
NCI Thesaurus Property
C4912
NCI Thesaurus Property-2
C16899
NCI Thesaurus Property-3
C25689
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C0699885
UMLS CUI-2
C1300072
Zubrod performance status
Description

Zubrod performance status

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ObjectClass
C25400
NCI Thesaurus Property
C25689
UMLS CUI-1
C3714786
Patient Eligibility
Description

Patient Eligibility

Has the SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
Description

Eligibility Determination

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
C1519429
UMLS CUI-2
C0013893
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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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header module
Clinical Study Protocol Amendment Activation Date
Item
Activation Date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C64382 (NCI Thesaurus Property)
C41200 (NCI Thesaurus Property-2)
C1515882 (UMLS CUI-1)
Data Amended Last Date
Item
Last Amended Date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C25551 (NCI Thesaurus ValueDomain-2)
C0011008 (UMLS CUI-1)
C1517741 (UMLS CUI-2)
Registration status
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C0585727 (UMLS CUI-1)
Item Group
Swog Patient Id
Patient Southwest Oncology GroupIdentifier Number
Item
SWOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C1519429 (UMLS CUI-1)
C3259154 (UMLS CUI-2)
Registrar Southwest Oncology Group Identifier Number
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)
C0600091 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
Southwest Oncology Group Investigator Identifie rNumber
Item
SWOG Investigator Number
float
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C0600091 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
Southwes Oncology Group Treating Institution Identifier Number
Item
SWOG Treating Institution Number
float
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)
C1522326 (UMLS CUI-2)
C0600091 (UMLS CUI-3)
Item Group
Stratification Questions
Item
Neoadjuvant chemotherapy
text
C25320 (NCI Thesaurus ObjectClass)
C15632 (NCI Thesaurus Property)
C15665 (NCI Thesaurus Property-2)
C25689 (NCI Thesaurus Property-3)
C25162 (NCI Thesaurus ValueDomain)
C0600558 (UMLS CUI-1)
C3665472 (UMLS CUI-2)
CL.1
Code List
Neoadjuvant chemotherapy
CL Item
Cisplatin Based (1)
C0008838 (UMLS CUI-1)
C0178499 (UMLS CUI-2)
CL Item
Carboplatin Based (2)
C0079083 (UMLS CUI-1)
C0178499 (UMLS CUI-2)
CL Item
Other (3)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
CL Item
None (4)
C41132 (NCI Thesaurus)
C0549184 (UMLS CUI-1)
Item
Clinical stage
text
C15206 (NCI Thesaurus ObjectClass)
C4912 (NCI Thesaurus Property)
C16899 (NCI Thesaurus Property-2)
C25689 (NCI Thesaurus Property-3)
C25162 (NCI Thesaurus ValueDomain)
C0699885 (UMLS CUI-1)
C1300072 (UMLS CUI-2)
Clinical Study Stage Bladder Carcinoma
Code List
Clinical stage
CL Item
T2 (1)
CL Item
T3 Or T4a (2)
Item
Zubrod performance status
text
C25162 (NCI Thesaurus ValueDomain)
C25400 (NCI Thesaurus ObjectClass)
C25689 (NCI Thesaurus Property)
C3714786 (UMLS CUI-1)
Zubrod Performance Status
Code List
Zubrod performance status
CL Item
0-1 (1)
CL Item
2 (2)
Item Group
Patient Eligibility
Eligibility Determination
Item
Has the SWOG 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)
C1519429 (UMLS CUI-1)
C0013893 (UMLS CUI-2)
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