Investigator Name
Item
Investigator Name
text
C2826892 (UMLS CUI [1])
Person Completing Form
Item
Form Completed by
text
C1550483 (UMLS CUI [1])
Form Completion Date
Item
Date
date
C1549507 (UMLS CUI [1])
Telephone number
Item
Telephone number
integer
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus Property)
C19711 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI [1])
Fax number
Item
Fax number
integer
C25704 (NCI Thesaurus ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C42775 (NCI Thesaurus Property)
C1549619 (UMLS CUI [1])
Item
Waiver request information
integer
C2699053 (UMLS CUI [1])
Code List
Waiver request information
CL Item
Screening Eligibility (1)
CL Item
Treatment Eligibility (2)
Screening Eligibility Waiver
Item
If screening eligibility: Criterion Letter(s):
text
C1707901 (UMLS CUI [1])
Screening Eligibility Waiver
Item
If treatment eligibility: Criterion Number(s):
integer
C1707901 (UMLS CUI [1])
Reason for waiver request
Item
Reason for waiver request
text
C2699053 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Clinical Name
Item
Clinical Name (please print)
text
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Signature Date
Item
Date
date
C0807937 (UMLS CUI [1])
Clinical Name
Item
Clinical Name (please print)
text
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Signature Date
Item
Date
date
C0807937 (UMLS CUI [1])
Item
Waiver Request
integer
C2699053 (UMLS CUI [1])
CL Item
Request approved (1)
CL Item
Request denied (specify reason) (2)
Reason for denial of waiver request
Item
If request denied, specify reason:
text
C2699053 (UMLS CUI [1,1])
C3274861 (UMLS CUI [1,2])