ID

1232

Beschreibung

GOG Registration Form Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA2B7A3-17EC-2382-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA2B7A3-17EC-2382-E034-0003BA12F5E7

Stichworte

Versionen (3)
  1. 27.08.12 27.08.12 -
  2. 26.06.17 26.06.17 - Martin Dugas
  3. 15.03.21 15.03.21 - Dr. rer. medic Philipp Neuhaus
Hochgeladen am

27. August 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0
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Cervical Cancer NCT00064077 Registration - GOG Registration Form - 2058698v3.0

Englisch

FORM R

1 Formulare  
  1. StudyEvent: GOG Registration Form
    1. FORM R
Header Module
Beschreibung

Header Module

Date form originally completed (m d y)
Beschreibung

FormCompletionDate,Original

Datentyp

date

Date form amended (m d y)
Beschreibung

FormCompletionDate,Amended

Datentyp

date

Person amending form, last name
Beschreibung

ResponsiblePersonReportingChangeLastName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Name, Last
Beschreibung

PatientName,Last

Datentyp

text

Patient Name, First
Beschreibung

PatientName,First

Datentyp

text

Patient Study ID
Beschreibung

PatientStudyID

Datentyp

text

Person Completing Form, Last Name
Beschreibung

PersonCompletingForm,LastName

Datentyp

text

Tracking Information
Beschreibung

Tracking Information

Institution name (affiliate)
Beschreibung

InstitutionName

Datentyp

text

Treating physician
Beschreibung

TreatingPhysician

Datentyp

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Patient medical record number
Beschreibung

PatientMedicalRecordNumber

Datentyp

text

Patient's date of birth
Beschreibung

PatientBirthDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient social security number
Beschreibung

PatientSocialSecurityNumber

Datentyp

double

Patient's zip code (USA)
Beschreibung

PatientAddress,PostalCode

Datentyp

double

Country of residence (if not USA)
Beschreibung

PatientAddress,Country

Datentyp

text

Demographic Information
Beschreibung

Demographic Information

Patient race (mark all that apply)
Beschreibung

PatientRace

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Patient ethnicity (check one)
Beschreibung

PatientEthnicity

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Method of payment
Beschreibung

PaymentMethod

Datentyp

text

Other (Payment Method), specify
Beschreibung

PatientPaymentSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25371
UMLS 2011AA Property
C0680264
Patient height (cm)
Beschreibung

PatientHeight

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25347
UMLS 2011AA Property
C0489786
Patient weight (kg)
Beschreibung

PatientWeight

Datentyp

double

Performance status (Zubrod)
Beschreibung

PerformanceStatus

Datentyp

text

Has the patient had any prior cancer diagnosed?
Beschreibung

PriorCancerInd

Datentyp

text

Prior cancer type
Beschreibung

PriorCancerType

Datentyp

text

Prior cancer diagnosis date
Beschreibung

PriorCancerDiagnosisDate

Datentyp

date

Comments
Beschreibung

Comments

COMMENTS
Beschreibung

Comments

Datentyp

text

Footer Module
Beschreibung

Footer Module

Participating Group Code
Beschreibung

ParticipatingGroupCode

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Participating Group Protocol Number
Beschreibung

ParticipatingGroupProtocolNumber

Datentyp

double

Participating Patient Study ID
Beschreibung

PatientParticipatingIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Ccrr Module For Gog Registration Form
Beschreibung

Ccrr Module For Gog Registration Form

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Ähnliche Modelle

FORM R

1 Formulare
  1. StudyEvent: GOG Registration Form
    1. FORM R
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header Module
FormCompletionDate,Original
Item
Date form originally completed (m d y)
date
FormCompletionDate,Amended
Item
Date form amended (m d y)
date
ResponsiblePersonReportingChangeLastName
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientStudyID
Item
Patient Study ID
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
Item Group
Tracking Information
InstitutionName
Item
Institution name (affiliate)
text
TreatingPhysician
Item
Treating physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
PatientMedicalRecordNumber
Item
Patient medical record number
text
PatientBirthDate
Item
Patient's date of birth
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
PatientSocialSecurityNumber
Item
Patient social security number
double
PatientAddress,PostalCode
Item
Patient's zip code (USA)
double
PatientAddress,Country
Item
Country of residence (if not USA)
text
Item Group
Demographic Information
Item
Patient race (mark all that apply)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.1
Code List
Patient race (mark all that apply)
CL Item
Native_american_cdus (American Indian or Alaska Native)
CL Item
Asian_cdus (Asian)
CL Item
Black_cdus (Black or African)
CL Item
Pacific_islander_cdus (Native Hawaiian or other Pacific Islander)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
White_cdus (White)
Item
Patient ethnicity (check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.2
Code List
Patient ethnicity (check one)
CL Item
Hispanic_or_latino (Hispanic or Latino)
CL Item
Non_hispanic (Non-Hispanic)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Method of payment
text
CL.3
Code List
Method of payment
CL Item
Private Insurance (Private)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare/Private)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid & Medicare)
CL Item
Military Or Veterans Sponsored Nos (Military or Veterans Sponsored NOS)
CL Item
Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS or TRICARE))
CL Item
Veterans Sponsored (Veterans Sponsored)
CL Item
Self Pay (no Insurance) (Self pay (no insurance))
CL Item
No Means Of Payment (no Insurance) (No means of payment (no insurance))
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientPaymentSpecify
Item
Other (Payment Method), specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS 2011AA Property)
PatientHeight
Item
Patient height (cm)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
PatientWeight
Item
Patient weight (kg)
double
Item
Performance status (Zubrod)
text
CL.4
Code List
Performance status (Zubrod)
CL Item
0 (0 = Fully active, able to carry on all pre-disease performance without restriction (Kamofsky 90-100))
C0919414 (NCI Metathesaurus)
CL Item
1 (1 = Restricted in physically strenuous activity, but ambulatory (K 70-80))
CL Item
2 (2 = Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50-60))
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3 = Capable of only limited selfcare, confined to bed or chair for more than 50% of waking hours (K 30-40))
CL Item
4 (4 = Completely disabled (K 10-20))
Item
Has the patient had any prior cancer diagnosed?
text
CL.5
Code List
Has the patient had any prior cancer diagnosed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorCancerType
Item
Prior cancer type
text
PriorCancerDiagnosisDate
Item
Prior cancer diagnosis date
date
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Footer Module
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
ParticipatingGroupProtocolNumber
Item
Participating Group Protocol Number
double
PatientParticipatingIdentifierNumber
Item
Participating Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Ccrr Module For Gog Registration Form
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