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ID

1588

Descrizione

E2205 Registration Worksheet (step 1) Chemotherapy, Radiation Therapy, and Cetuximab Followed by Surgery, Docetaxel, and Cetuximab in Treating Patients With Esophageal Cancer or Gastroesophageal Junction Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4E4AEBDF-A595-00B2-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4E4AEBDF-A595-00B2-E044-0003BA3F9857

Keywords

versioni (3)
  1. 19/09/12 19/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
  3. 17/09/21 17/09/21 -
Caricato su

19 settembre 2012

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy
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    Esophageal Cancer NCT00551759 Eligibility - E2205 Registration Worksheet (step 1) - 2753343v1.0

    Inglese

    No Instruction available.

    1 moduli  
    1. StudyEvent: E2205 Registration Worksheet (step 1)
      1. No Instruction available.
    Eligibility
    Descrizione

    Eligibility

    First initial
    Descrizione

    PatientFirstInitialsName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    Last initial
    Descrizione

    PatientLastInitialsName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    NCI Thesaurus Property
    C25551
    UMLS 2011AA Property
    C1517741
    Has the eligibility checklist been completed
    Descrizione

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C25171
    UMLS 2011AA ObjectClass
    C0013893
    NCI Thesaurus Property
    C49073
    UMLS 2011AA Property
    C1707357
    In the opinion of the investigator, is the patient eligible?
    Descrizione

    PatientEligibilityIndicator

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    Has written informed consent been obtained
    Descrizione

    PatientSignatureConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    Date Informed Consent Signed
    Descrizione

    InformedConsentFormSignedDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Has HIPAA authorization been obtained
    Descrizione

    HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C62504
    UMLS 2011AA ObjectClass
    C0600593
    NCI Thesaurus Property
    C41192
    UMLS 2011AA Property
    C1524004
    HIPAA Authorization Date
    Descrizione

    PatientSignedDischargeMedicalRecordDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25679
    NCI Metathesaurus Property
    C0012621
    NCI Thesaurus Property
    C45258
    UMLS 2011AA Property
    C0025102
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    ECOG Performance Status
    Descrizione

    PerformanceStatusAssessmentEasternCooperativeOncologyGroupScale

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain
    C25491
    UMLS 2011AA ValueDomain
    C1512162
    NCI Thesaurus ObjectClass
    C20641
    UMLS 2011AA ObjectClass
    C1518965
    Clinical Stage
    Descrizione

    SarcomaTNMStageGroupingCategory

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C9118
    UMLS 2011AA ObjectClass
    C1261473
    NCI Thesaurus Property
    C25384
    UMLS 2011AA Property
    C1515169
    NCI Thesaurus Property
    C38027
    UMLS 2011AA Property
    C1519504
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    Descrizione

    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property
    C25294
    UMLS 2011AA Property
    C0022885
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Descrizione

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property
    C9305
    UMLS 2011AA Property
    C0006826
    NCI Thesaurus Property
    C19157
    UMLS 2011AA Property
    C0370003
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    Descrizione

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus Property
    C12801
    UMLS 2011AA Property
    C0040300
    NCI Thesaurus Property
    C19157
    UMLS 2011AA Property
    C0370003
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Someone may contact me in the future to ask me to allow other uses of my specimens.
    Descrizione

    PatientContactConsentInd-3

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C67527
    UMLS 2011AA Property
    C0016884
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus Property
    C16452
    UMLS 2011AA Property
    C0009452
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Name of the contact person responsible for sample submission
    Descrizione

    SpecimenSubmissionContactPersonIdentifierName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C25461
    UMLS 2011AA ObjectClass
    C0337611
    NCI Thesaurus ObjectClass
    C25694
    UMLS 2011AA ObjectClass
    C1515022
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Phone number of the contact person responsible for sample submission
    Descrizione

    SpecimenSubmissionContactPersonTelephoneNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C25461
    UMLS 2011AA ObjectClass
    C0337611
    NCI Thesaurus ObjectClass
    C25694
    UMLS 2011AA ObjectClass
    C1515022
    NCI Thesaurus Property
    C40978
    UMLS 2011AA Property
    C1515258
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ValueDomain
    C25395
    UMLS 2011AA ValueDomain
    C0039457
    Fax number of the contact person responsible for sample submission
    Descrizione

    SpecimenSubmissionContactPersonFaxNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C25461
    UMLS 2011AA ObjectClass
    C0337611
    NCI Thesaurus ObjectClass
    C25694
    UMLS 2011AA ObjectClass
    C1515022
    NCI Thesaurus Property
    C42879
    UMLS 2011AA Property
    C1549619
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ValueDomain
    C25395
    UMLS 2011AA ValueDomain
    C0039457
    E-mail address of the contact person responsible for sample submission
    Descrizione

    SpecimenSubmissionContactPersonE-mailAddressText

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C25461
    UMLS 2011AA ObjectClass
    C0337611
    NCI Thesaurus ObjectClass
    C25694
    UMLS 2011AA ObjectClass
    C1515022
    NCI Thesaurus Property
    C42775
    UMLS 2011AA Property
    C1705961
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    If an ECOG patient is to receive radiation therapy, will it be given at the registering institution
    Descrizione

    RadiationTherapyEnrollmentInstitutionAdministrationIndicator

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C41206
    UMLS 2011AA Property
    C1272753
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus Property
    C37948
    UMLS 2011AA Property
    C1516879
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Name of the institution that will administered the radiation therapy
    Descrizione

    InstitutionRadiationTherapyAdministrationName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C41206
    UMLS 2011AA ObjectClass
    C1272753
    NCI Thesaurus Property
    C15313
    UMLS 2011AA Property
    C1522449
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Patient Demographics / Pre-treatment Characteristics
    Descrizione

    Patient Demographics / Pre-treatment Characteristics

    Patient's Sex
    Descrizione

    PatientSexCode

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C28421
    UMLS 2011AA Property
    C1522384
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ValueDomain
    C16960
    UMLS 2011AA ValueDomain
    C0030705
    NCI Thesaurus ValueDomain
    C28421
    UMLS 2011AA ValueDomain
    C1522384
    Birthdate (mm/yy)
    Descrizione

    PatientBirthDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25155
    UMLS 2011AA Property
    C0005615
    Patient Race (check all that applyU.S. and Canada only)
    Descrizione

    PatientRaceCategory

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    ZIP Code
    Descrizione

    AddressPostalCodeIdentifier

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C25407
    UMLS 2011AA ObjectClass
    C1442065
    NCI Thesaurus Property
    C25621
    UMLS 2011AA Property
    C1514254
    NCI Thesaurus ValueDomain
    C25364
    UMLS 2011AA ValueDomain
    C0600091
    NCI Thesaurus ValueDomain
    C25407
    UMLS 2011AA ValueDomain
    C1442065
    NCI Thesaurus ValueDomain
    C25621
    UMLS 2011AA ValueDomain
    C1514254
    Patient Hospital No.
    Descrizione

    PatientMedicalRecordNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25261
    UMLS 2011AA Property
    C0205476
    NCI Thesaurus Property
    C25198
    UMLS 2011AA Property
    C0034869
    Patient Social Security Number
    Descrizione

    PatientSSNNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25686
    UMLS 2011AA Property
    C1301821
    Method of payment (check one)
    Descrizione

    PatientInternationalPaymentType

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25371
    UMLS 2011AA Property
    C0680264
    NCI Thesaurus Property
    C25541
    UMLS 2011AA Property
    C1512888
    Attending Physician
    Descrizione

    AttendingPhysicianIdentifierIndividualsName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Metathesaurus ObjectClass
    CL317115
    Institution contact
    Descrizione

    InstitutionContactPersonName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25461
    UMLS 2011AA ObjectClass
    C0337611
    Registrar
    Descrizione

    ProtocolRegistrarName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25357
    UMLS 2011AA ObjectClass
    C0557514
    Country of Residence
    Descrizione

    PatientAddressCountryName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C25464
    UMLS 2011AA ValueDomain
    C0454664
    NCI Thesaurus Property
    C25407
    UMLS 2011AA Property
    C1442065
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Comments
    Descrizione

    ResearchCommentsText

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Signature of treating physician (I have reviewed the above data and agree the date are accurate and correct)
    Descrizione

    TreatingPhysicianSignatureText

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C51883
    UMLS 2011AA ObjectClass
    C1710470
    Date (Note: Date must be on or before date of registration)
    Descrizione

    TreatingPhysicianSignatureDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C51883
    UMLS 2011AA ObjectClass
    C1710470
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    No Instruction available.

    1 moduli
    1. StudyEvent: E2205 Registration Worksheet (step 1)
      1. No Instruction available.
    Name
    genere
    Description | Question | Decode (Coded Value)
    Tipo di dati
    Alias
    Item Group
    Eligibility
    PatientFirstInitialsName
    Item
    First initial
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    PatientLastInitialsName
    Item
    Last initial
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus Property)
    C1517741 (UMLS 2011AA Property)
    Item
    Has the eligibility checklist been completed
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus ObjectClass)
    C0013893 (UMLS 2011AA ObjectClass)
    C49073 (NCI Thesaurus Property)
    C1707357 (UMLS 2011AA Property)
    CL.1
    Code List
    Has the eligibility checklist been completed
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    In the opinion of the investigator, is the patient eligible?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    CL.2
    Code List
    In the opinion of the investigator, is the patient eligible?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Has written informed consent been obtained
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    CL.3
    Code List
    Has written informed consent been obtained
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    Item
    Has HIPAA authorization been obtained
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C62504 (NCI Thesaurus ObjectClass)
    C0600593 (UMLS 2011AA ObjectClass)
    C41192 (NCI Thesaurus Property)
    C1524004 (UMLS 2011AA Property)
    CL.4
    Code List
    Has HIPAA authorization been obtained
    CL Item
    No: C49487 (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes: C49488 (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Exempt - Non-usa Participant (Exempt - non-USA participant)
    PatientSignedDischargeMedicalRecordDate
    Item
    HIPAA Authorization Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C0012621 (NCI Metathesaurus Property)
    C45258 (NCI Thesaurus Property)
    C0025102 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    ECOG Performance Status
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain)
    C1512162 (UMLS 2011AA ValueDomain)
    C20641 (NCI Thesaurus ObjectClass)
    C1518965 (UMLS 2011AA ObjectClass)
    CL.5
    Code List
    ECOG Performance Status
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    CL Item
    Dead (5)
    Item
    Clinical Stage
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C9118 (NCI Thesaurus ObjectClass)
    C1261473 (UMLS 2011AA ObjectClass)
    C25384 (NCI Thesaurus Property)
    C1515169 (UMLS 2011AA Property)
    C38027 (NCI Thesaurus Property)
    C1519504 (UMLS 2011AA Property)
    CL.6
    Code List
    Clinical Stage
    CL Item
    T1-3n+m0 (T1-3N+M0)
    CL Item
    T1-3n0-1m1a (T1-3N0-1M1A)
    CL Item
    T2n0m0 (T2N0M0)
    CL Item
    T3n0m0 (T3N0M0)
    Item
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C15207 (NCI Thesaurus Property)
    C25294 (NCI Thesaurus Property)
    C0022885 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.7
    Code List
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C9305 (NCI Thesaurus Property)
    C0006826 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property)
    C0370003 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.8
    Code List
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C12801 (NCI Thesaurus Property)
    C0040300 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property)
    C0370003 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.9
    Code List
    My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Someone may contact me in the future to ask me to allow other uses of my specimens.
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C67527 (NCI Thesaurus Property)
    C0016884 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C16452 (NCI Thesaurus Property)
    C0009452 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.10
    Code List
    Someone may contact me in the future to ask me to allow other uses of my specimens.
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    SpecimenSubmissionContactPersonIdentifierName
    Item
    Name of the contact person responsible for sample submission
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus ObjectClass)
    C0337611 (UMLS 2011AA ObjectClass)
    C25694 (NCI Thesaurus ObjectClass)
    C1515022 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    SpecimenSubmissionContactPersonTelephoneNumber
    Item
    Phone number of the contact person responsible for sample submission
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus ObjectClass)
    C0337611 (UMLS 2011AA ObjectClass)
    C25694 (NCI Thesaurus ObjectClass)
    C1515022 (UMLS 2011AA ObjectClass)
    C40978 (NCI Thesaurus Property)
    C1515258 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25395 (NCI Thesaurus ValueDomain)
    C0039457 (UMLS 2011AA ValueDomain)
    SpecimenSubmissionContactPersonFaxNumber
    Item
    Fax number of the contact person responsible for sample submission
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus ObjectClass)
    C0337611 (UMLS 2011AA ObjectClass)
    C25694 (NCI Thesaurus ObjectClass)
    C1515022 (UMLS 2011AA ObjectClass)
    C42879 (NCI Thesaurus Property)
    C1549619 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25395 (NCI Thesaurus ValueDomain)
    C0039457 (UMLS 2011AA ValueDomain)
    SpecimenSubmissionContactPersonE-mailAddressText
    Item
    E-mail address of the contact person responsible for sample submission
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25461 (NCI Thesaurus ObjectClass)
    C0337611 (UMLS 2011AA ObjectClass)
    C25694 (NCI Thesaurus ObjectClass)
    C1515022 (UMLS 2011AA ObjectClass)
    C42775 (NCI Thesaurus Property)
    C1705961 (UMLS 2011AA Property)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    Item
    If an ECOG patient is to receive radiation therapy, will it be given at the registering institution
    text
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C41206 (NCI Thesaurus Property)
    C1272753 (UMLS 2011AA Property)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C37948 (NCI Thesaurus Property)
    C1516879 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    If an ECOG patient is to receive radiation therapy, will it be given at the registering institution
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable - Not An Ecog Patient (Not applicable - not an ECOG patient)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    InstitutionRadiationTherapyAdministrationName
    Item
    Name of the institution that will administered the radiation therapy
    text
    C41206 (NCI Thesaurus ObjectClass)
    C1272753 (UMLS 2011AA ObjectClass)
    C15313 (NCI Thesaurus Property)
    C1522449 (UMLS 2011AA Property)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    Item Group
    Patient Demographics / Pre-treatment Characteristics
    Item
    Patient's Sex
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28421 (NCI Thesaurus Property)
    C1522384 (UMLS 2011AA Property)
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ValueDomain)
    C0030705 (UMLS 2011AA ValueDomain)
    C28421 (NCI Thesaurus ValueDomain)
    C1522384 (UMLS 2011AA ValueDomain)
    CL.12
    Code List
    Patient's Sex
    CL Item
    Female (F)
    C16576 (NCI Thesaurus)
    C0015780 (UMLS 2011AA)
    CL Item
    Male (M)
    C20197 (NCI Thesaurus)
    C0024554 (UMLS 2011AA)
    PatientBirthDate
    Item
    Birthdate (mm/yy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25155 (NCI Thesaurus Property)
    C0005615 (UMLS 2011AA Property)
    Item
    Patient Race (check all that applyU.S. and Canada only)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    CL.13
    Code List
    Patient Race (check all that applyU.S. and Canada only)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
    C41261 (NCI Thesaurus)
    C0007457 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
    C16352 (NCI Thesaurus)
    C0085756 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
    C41260 (NCI Thesaurus)
    C0078988 (UMLS 2011AA)
    CL Item
    Not Provided Or Available (Not Reported)
    C43234 (NCI Thesaurus)
    C1706613 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
    C41219 (NCI Thesaurus)
    C1513907 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
    C41259 (NCI Thesaurus)
    C1515945 (UMLS 2011AA)
    CL Item
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    AddressPostalCodeIdentifier
    Item
    ZIP Code
    text
    C25407 (NCI Thesaurus ObjectClass)
    C1442065 (UMLS 2011AA ObjectClass)
    C25621 (NCI Thesaurus Property)
    C1514254 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus ValueDomain)
    C0600091 (UMLS 2011AA ValueDomain)
    C25407 (NCI Thesaurus ValueDomain)
    C1442065 (UMLS 2011AA ValueDomain)
    C25621 (NCI Thesaurus ValueDomain)
    C1514254 (UMLS 2011AA ValueDomain)
    PatientMedicalRecordNumber
    Item
    Patient Hospital No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25261 (NCI Thesaurus Property)
    C0205476 (UMLS 2011AA Property)
    C25198 (NCI Thesaurus Property)
    C0034869 (UMLS 2011AA Property)
    PatientSSNNumber
    Item
    Patient Social Security Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25686 (NCI Thesaurus Property)
    C1301821 (UMLS 2011AA Property)
    Item
    Method of payment (check one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25371 (NCI Thesaurus Property)
    C0680264 (UMLS 2011AA Property)
    C25541 (NCI Thesaurus Property)
    C1512888 (UMLS 2011AA Property)
    CL.14
    Code List
    Method of payment (check one)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    CL Item
    Military Or Veterans Sponsored Nos (Military or Veterans Sponsored, Not Otherwise Specified (NOS))
    CL Item
    Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
    CL Item
    National Health Service (National Health Service)
    CL Item
    No Means Of Payment (no Insurance) (No means of payment (no insurance))
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Self Pay (no Insurance) (Self Pay (No Insurance))
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Veterans Sponsored (Veterans Sponsored)
    AttendingPhysicianIdentifierIndividualsName
    Item
    Attending Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CL317115 (NCI Metathesaurus ObjectClass)
    InstitutionContactPersonName
    Item
    Institution contact
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25461 (NCI Thesaurus ObjectClass)
    C0337611 (UMLS 2011AA ObjectClass)
    ProtocolRegistrarName
    Item
    Registrar
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS 2011AA ObjectClass)
    PatientAddressCountryName
    Item
    Country of Residence
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25464 (NCI Thesaurus ValueDomain)
    C0454664 (UMLS 2011AA ValueDomain)
    C25407 (NCI Thesaurus Property)
    C1442065 (UMLS 2011AA Property)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
    TreatingPhysicianSignatureText
    Item
    Signature of treating physician (I have reviewed the above data and agree the date are accurate and correct)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C51883 (NCI Thesaurus ObjectClass)
    C1710470 (UMLS 2011AA ObjectClass)
    TreatingPhysicianSignatureDate
    Item
    Date (Note: Date must be on or before date of registration)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C51883 (NCI Thesaurus ObjectClass)
    C1710470 (UMLS 2011AA ObjectClass)
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