Information:
Error:
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
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 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.
- StudyEvent: CALGB 90104 Registration Worksheet
Similar models
No Instruction available.
- StudyEvent: CALGB 90104 Registration Worksheet
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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
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
CL Item
Male (M)
CL Item
Female (F)
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)
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
CL Item
T3 (T3)
CL Item
T4 (T4)
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)