ID

11763

Description

Registration Worksheet - 2169258v3.0 CALGB 90104 Registration Worksheet Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B0241-438C-6AC6-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B0241-438C-6AC6-E034-0003BA12F5E7

Keywords

  1. 8/26/12 8/26/12 -
  2. 7/30/15 7/30/15 - Martin Dugas
Uploaded on

July 30, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Registration Bladder Cancer CALGB 90104 NCT00014534

No Instruction available.

  1. StudyEvent: CALGB 90104 Registration Worksheet
    1. No Instruction available.
Initial Patient Consent For Specimen Use
Description

Initial Patient Consent For Specimen Use

Patient's Initial Consent given for specimen use for research on the patient's cancer?
Description

Patient's Initial Consent given for specimen use for research on the patient's cancer?

Data type

boolean

Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?
Description

Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?

Data type

boolean

Patient's Initial Consent given for further contact regarding specimen?
Description

Patient's Initial Consent given for further contact regarding specimen?

Data type

boolean

assigned CALGB patient ID
Description

assignedCALGBpatientID

Data type

text

Registration date
Description

Registration date

Data type

date

Alias
UMLS CUI-1-1
C2985881
Assigned Participating Group Patient ID
Description

AssignedParticipatingGroupPatientID

Data type

text

Registrar's Signature
Description

Registrar'sSignature

Data type

text

Ccrr Module For Calgb 90104 Registration Worksheet
Description

Ccrr Module For Calgb 90104 Registration Worksheet

Alias
UMLS CUI-1
C1514821
Institution Name
Description

InstitutionName

Data type

text

Affiliate Institution
Description

AffiliateInstitution

Data type

text

Physician of Record
Description

PhysicianofRecord

Data type

text

Participating Group Name
Description

ParticipatingGroupName

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

IRB Approval Date
Description

IRBApprovalDate

Data type

text

Date Informed Consent Signed
Description

DateInformedConsentSigned

Data type

text

Projected Treatment Start Date
Description

ProjectedTreatmentStartDate

Data type

text

HIPAA Authorization Date
Description

HIPAAAuthorizationDate

Data type

text

Responsible contact
Description

Responsiblecontact

Data type

text

phone
Description

phone

Data type

text

fax
Description

fax

Data type

text

Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI-1-1
C2986440
Patient Social Security Number
Description

PatientSocialSecurityNumber

Data type

text

Patient date of birth
Description

Patient date of birth

Data type

date

Measurement units
  • DD.MM.YYYY
Alias
UMLS CUI-1-1
C0421451
DD.MM.YYYY
Patient Hospital No.
Description

PatientHospitalNo.

Data type

text

Gender
Description

Gender

Data type

text

Alias
UMLS CUI-1-1
C0079399
Race
Description

Race

Data type

text

Performance Status (ECOG/Zubrod)
Description

PerformanceStatus(ECOG/Zubrod)

Data type

text

Height
Description

Height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI-1-1
C0005890
cm
Body weight
Description

Body weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI-1-1
C0005910
kg
Body surface area
Description

Body surface area

Data type

float

Measurement units
Alias
UMLS CUI-1-1
C0005902
Method of Payment
Description

MethodofPayment

Data type

text

Patient's zip code
Description

Patient'szipcode

Data type

text

Country of residence (if not USA)
Description

Countryofresidence(ifnotUSA)

Data type

text

T status
Description

Tstatus

Data type

text

Lymph node involvement
Description

Lymphnodeinvolvement

Data type

text

Similar models

No Instruction available.

  1. StudyEvent: CALGB 90104 Registration Worksheet
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Initial Patient Consent For Specimen Use
Consent for specimen use in cancer research
Item
Patient's Initial Consent given for specimen use for research on the patient's cancer?
boolean
Consent for specimen use in research
Item
Patient´s Initial Consent given for specimen use for research unrelated to the patient´s cancer?
boolean
Permission to contact patient
Item
Patient's Initial Consent given for further contact regarding specimen?
boolean
assignedCALGBpatientID
Item
assigned CALGB patient ID
text
Registration date
Item
Registration date
date
C2985881 (UMLS CUI-1-1)
AssignedParticipatingGroupPatientID
Item
Assigned Participating Group Patient ID
text
Registrar'sSignature
Item
Registrar's Signature
text
Item Group
Ccrr Module For Calgb 90104 Registration Worksheet
C1514821 (UMLS CUI-1)
InstitutionName
Item
Institution Name
text
AffiliateInstitution
Item
Affiliate Institution
text
PhysicianofRecord
Item
Physician of Record
text
ParticipatingGroupName
Item
Participating Group Name
text
CALGBPatientID
Item
CALGB Patient ID
text
IRBApprovalDate
Item
IRB Approval Date
text
DateInformedConsentSigned
Item
Date Informed Consent Signed
text
ProjectedTreatmentStartDate
Item
Projected Treatment Start Date
text
HIPAAAuthorizationDate
Item
HIPAA Authorization Date
text
Responsiblecontact
Item
Responsible contact
text
phone
Item
phone
text
fax
Item
fax
text
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI-1-1)
PatientSocialSecurityNumber
Item
Patient Social Security Number
text
Birth date
Item
Patient date of birth
date
C0421451 (UMLS CUI-1-1)
PatientHospitalNo.
Item
Patient Hospital No.
text
Item
Gender
text
C0079399 (UMLS CUI-1-1)
Code List
Gender
CL Item
Male (M)
CL Item
Female (F)
Item
Race
text
Code List
Race
CL Item
American Indian or Alaskan Native (American Indian or Alaskan Native)
CL Item
Asian (Asian)
CL Item
Black or African American (Black or African American)
CL Item
Native Hawaiian or Other Pacific Islander (Native Hawaiian or Other Pacific Islander)
CL Item
Unknown (Unknown)
CL Item
White (White)
CL Item
Ethnicity (Ethnicity)
CL Item
Hispanic or Latino (Hispanic or Latino)
CL Item
Non-Hispanic (Non-Hispanic)
CL Item
Unknown (Unknown)
PerformanceStatus(ECOG/Zubrod)
Item
Performance Status (ECOG/Zubrod)
text
Height
Item
Height
float
C0005890 (UMLS CUI-1-1)
Weight
Item
Body weight
float
C0005910 (UMLS CUI-1-1)
BSA
Item
Body surface area
float
C0005902 (UMLS CUI-1-1)
Item
Method of Payment
text
Code List
Method of Payment
CL Item
medicaid (medicaid)
CL Item
medicare and private insurance (medicare and private insurance)
CL Item
other (other)
CL Item
self pay (no insurance) (self pay (no insurance))
CL Item
medicaid and medicare (medicaid and medicare)
CL Item
military (including Champus and Tricare) (military (including Champus and Tricare))
CL Item
private insurance (private insurance)
CL Item
unknown (unknown)
CL Item
medicare (medicare)
CL Item
no means of payment (no insurance) (no means of payment (no insurance))
CL Item
veterans administration sponsored (veterans administration sponsored)
Patient'szipcode
Item
Patient's zip code
text
Countryofresidence(ifnotUSA)
Item
Country of residence (if not USA)
text
Item
T status
text
Code List
T status
CL Item
T3 (T3)
CL Item
T4 (T4)
Item
Lymph node involvement
text
Code List
Lymph node involvement
CL Item
absent (absent)
CL Item
1 to 5 nodes invovled by tumor (1 to 5 nodes invovled by tumor)
CL Item
greater than or equal to 6 nodes involved by tumor (greater than or equal to 6 nodes involved by tumor)
CL Item
A (A)
CL Item
B (B)

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