ID

1197

Descrizione

Southwest Oncology Group Registration Form (S0227) S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C4563A-B1F7-3ACF-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C4563A-B1F7-3ACF-E034-0003BA12F5E7

Keywords

versioni (3)
  1. 27/08/12 27/08/12 -
  2. 29/04/15 29/04/15 - Martin Dugas
  3. 27/09/21 27/09/21 -
Caricato su

27 agosto 2012

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00057928 Registration - Southwest Oncology Group Registration Form (S0227) - 2057289v3.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: Southwest Oncology Group Registration Form (S0227)
    1. No Instruction available.
Unnamed1
Descrizione

Unnamed1

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Assigned Treatment Arm
Descrizione

TreatmentArmNumber

Tipo di dati

text

Activation Date
Descrizione

ActivationDate

Tipo di dati

date

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

DataAmendedLastDate

Tipo di dati

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
C25551
UMLS 2011AA ValueDomain
C1517741
Unnamed2
Descrizione

Unnamed2

Patient's Name
Descrizione

Patient'sName

Tipo di dati

text

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

Other Group Patient Number
Descrizione

OtherGroupPatientIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C43359
UMLS 2011AA ObjectClass
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Name/Protocol Number
Descrizione

Particip.GroupProtocolNumber

Tipo di dati

double

Unnamed3
Descrizione

Unnamed3

Unnamed4
Descrizione

Unnamed4

Caller's SWOG Roster ID
Descrizione

RegistrarSouthwestOncologyGroupIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25699
UMLS 2011AA Property
C1519429
NCI Thesaurus ObjectClass
C25357
UMLS 2011AA ObjectClass
C0557514
IRB Approval Date
Descrizione

IRBApprovalDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Date Informed Consent Signed
Descrizione

InformedConsentDateSigned

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Projected Start Date of Treatment
Descrizione

ProjectedTreatmentBeginDate

Tipo di dati

date

SWOG Investigator Number
Descrizione

SWOGInvestigatorNumber

Tipo di dati

text

Other Group Investigator Name
Descrizione

PrincipalInvestigatorName

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C19924
UMLS 2011AA ObjectClass
C1521895
Other Group Investigator Number
Descrizione

NationalCancerInstitutePrincipalInvestigatorIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C19202
UMLS 2011AA ObjectClass
C1513882
NCI Thesaurus ObjectClass
C19924
UMLS 2011AA ObjectClass
C1521895
SWOG Institution Number
Descrizione

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Tipo di dati

double

Alias
NCI Thesaurus ObjectClass
C25699
UMLS 2011AA ObjectClass
C1519429
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
NCI Thesaurus ObjectClass
C41206
UMLS 2011AA ObjectClass
C1272753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Institution Name
Descrizione

InstitutionName

Tipo di dati

text

Other Group Institution Number
Descrizione

NCIInstitutionNumber

Tipo di dati

text

Unnamed5
Descrizione

Unnamed5

Patient's Date of Birth
Descrizione

PatientBirthDate

Tipo di dati

date

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

PatientGender

Tipo di dati

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
Descrizione

PaymentMethod

Tipo di dati

text

Patient's Ethnicity
Descrizione

PatientEthnicity

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Patient's Race (select all that apply)
Descrizione

PatientRace

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Patient's Social Security Number
Descrizione

PatientSocialSecurityNumber

Tipo di dati

double

Postal Code
Descrizione

PatientAddress,PostalCode

Tipo di dati

double

Postal Code
Descrizione

PatientAddress,PostalCode

Tipo di dati

double

Country of Residence (If a resident of Canada)
Descrizione

PatientAddress,Country

Tipo di dati

text

Social Insurance Number
Descrizione

PatientSocialInsuranceIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C62650
UMLS 2011AA ObjectClass
C0728831
NCI Thesaurus ObjectClass
C16745
UMLS 2011AA ObjectClass
C0021672
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Comments
Descrizione

Comments

Comments
Descrizione

Comments

Tipo di dati

text

Ccrr Module For Southwest Oncology Group Registration Form (s0227)
Descrizione

Ccrr Module For Southwest Oncology Group Registration Form (s0227)

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: Southwest Oncology Group Registration Form (S0227)
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Unnamed1
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
TreatmentArmNumber
Item
Assigned Treatment Arm
text
ActivationDate
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C64382 (NCI Thesaurus Property)
C1879547 (UMLS 2011AA Property)
C41200 (NCI Thesaurus Property)
C0680532 (UMLS 2011AA Property)
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)
C1517741 (UMLS 2011AA ValueDomain)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
OtherGroupPatientIdentifierNumber
Item
Other Group Patient Number
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C43359 (NCI Thesaurus ObjectClass)
C0441833 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Particip.GroupProtocolNumber
Item
Other Group Name/Protocol Number
double
Item Group
Unnamed3
Item Group
Unnamed4
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)
C1519429 (UMLS 2011AA Property)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
PrincipalInvestigatorName
Item
Other Group Investigator Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19924 (NCI Thesaurus ObjectClass)
C1521895 (UMLS 2011AA ObjectClass)
NationalCancerInstitutePrincipalInvestigatorIdentifierNumber
Item
Other Group Investigator Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19202 (NCI Thesaurus ObjectClass)
C1513882 (UMLS 2011AA ObjectClass)
C19924 (NCI Thesaurus ObjectClass)
C1521895 (UMLS 2011AA ObjectClass)
SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
Item
SWOG Institution Number
double
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Other Group Institution Name
text
NCIInstitutionNumber
Item
Other Group Institution Number
text
Item Group
Unnamed5
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.1
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)
PaymentMethod
Item
Method of Payment
text
PatientEthnicity
Item
Patient's Ethnicity
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
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.2
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)
PatientSocialSecurityNumber
Item
Patient's Social Security Number
double
PatientAddress,PostalCode
Item
Postal Code
double
PatientAddress,PostalCode
Item
Postal Code
double
PatientAddress,Country
Item
Country of Residence (If a resident of Canada)
text
PatientSocialInsuranceIdentifierNumber
Item
Social Insurance Number
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C62650 (NCI Thesaurus ObjectClass)
C0728831 (UMLS 2011AA ObjectClass)
C16745 (NCI Thesaurus ObjectClass)
C0021672 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group Registration Form (s0227)
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