ID

2098

Beschreibung

S0100 Registration Form-1 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB2F98C-212E-4168-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB2F98C-212E-4168-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 21.08.17 21.08.17 -
Hochgeladen am

19. September 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Leukemia null Registration - S0100 Registration Form-1 - 2031615v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: S0100 Registration Form-1
    1. No Instruction available.
Patient Consent For Specimen Use:
Beschreibung

Patient Consent For Specimen Use:

Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
Beschreibung

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datentyp

text

Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease.)
Beschreibung

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datentyp

text

Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
Beschreibung

PatientInitialConsent,Specimen,ContactInd

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's Sex
Beschreibung

PatientGender

Datentyp

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:
Beschreibung

PaymentMethod

Datentyp

text

Patient's Ethnicity
Beschreibung

PatientEthnicity

Datentyp

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:)
Beschreibung

PatientRace

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
specify: (If a U.S. resident)
Beschreibung

RaceOther,specify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Patient's Social Security Number
Beschreibung

PatientSocialSecurityNumber

Datentyp

double

Patient's ZIP Code
Beschreibung

PatientAddress,PostalCode

Datentyp

double

Country of Residence, if not USA (If a resident of Canada)
Beschreibung

PatientAddress,Country

Datentyp

text

Social Insurance Number
Beschreibung

PatientSocialInsuranceIdentifierNumber

Datentyp

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
Postal Code
Beschreibung

AddressPostalCode

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25407
UMLS 2011AA ObjectClass
C1442065
NCI Thesaurus Property
C25621
UMLS 2011AA Property
C1514254
Stratification Factors
Beschreibung

Stratification Factors

Age
Beschreibung

PatientAge

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
Phenotype
Beschreibung

Phenotype

Datentyp

text

Notes
Beschreibung

Comments

Datentyp

text

Ccrr Module For S0100 Registration Form-1
Beschreibung

Ccrr Module For S0100 Registration Form-1

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Assigned Treatment Arm
Beschreibung

ProtocolTreatmentArmAssignmentText

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C32141
UMLS 2011AA Property
C1140618
NCI Thesaurus Property
C25426
UMLS 2011AA Property
C1516050
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Activation Date
Beschreibung

ActivationDate

Datentyp

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
Beschreibung

DataAmendedLastDate

Datentyp

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
Patient's Name
Beschreibung

Patient'sName

Datentyp

text

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

Caller's SWOG Roster ID
Beschreibung

RegistrarSouthwestOncologyGroupIdentifierNumber

Datentyp

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
SWOG Treating Institution Number
Beschreibung

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Datentyp

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
Date Informed Consent Signed
Beschreibung

InformedConsentDateSigned

Datentyp

text

SWOG Investigator Number
Beschreibung

SWOGInvestigatorNumber

Datentyp

text

IRB Approval Date
Beschreibung

IRBApprovalDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Beschreibung

ProjectedTreatmentBeginDate

Datentyp

date

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: S0100 Registration Form-1
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient Consent For Specimen Use:
Item
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
text
CL.1
Code List
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease.)
text
CL.2
Code List
Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease.)
CL Item
Null (Yes)
CL Item
Null (No)
Item
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
text
CL.3
Code List
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
CL Item
Null (Yes)
CL Item
Null (No)
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.4
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)
Item
Method of Payment:
text
CL.5
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 and Private)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Self Pay (no Insurance) (No insurance (self-pay))
CL Item
No Means Of Payment (no Insurance) (No insurance (no means))
CL Item
Other (Other, specify at registration)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Sponsored (Veterans Admin)
CL Item
Military Sponsored (including Champus & Tricare) (Military)
Item
Patient's Ethnicity
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.6
Code List
Patient's Ethnicity
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (not Spanish) (No (not Spanish))
CL Item
Yes, Mexican (Yes, Mexican)
CL Item
Yes,Puerto Rican (Yes,Puerto Rican)
CL Item
Yes, Cuban (Yes, Cuban)
CL Item
Yes, Central American (Yes, Central American)
CL Item
Yes, South American (Yes, South American)
CL Item
Yes,Other (Yes,Other)
CL Item
Yes, NOS (Yes, NOS)
CL Item
Hispanic_or_latino (HISPANIC OR LATINO)
CL Item
Non_hispanic (NON-HISPANIC)
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.7
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)
CL Item
Other, (Other,)
RaceOther,specify
Item
specify: (If a U.S. resident)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientSocialSecurityNumber
Item
Patient's Social Security Number
double
PatientAddress,PostalCode
Item
Patient's ZIP Code
double
PatientAddress,Country
Item
Country of Residence, if not USA (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)
AddressPostalCode
Item
Postal Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
Item Group
Stratification Factors
Item
Age
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
CL.8
Code List
Age
CL Item
<30 (<30)
CL Item
30-49 (30-49)
CL Item
50+ (50+)
Item
Phenotype
text
CL.9
Code List
Phenotype
CL Item
T-cell (T-cell)
CL Item
Pre-b (pre-B)
Comments
Item
Notes
text
Item Group
Ccrr Module For S0100 Registration Form-1
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
ProtocolTreatmentArmAssignmentText
Item
Assigned Treatment Arm
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C32141 (NCI Thesaurus Property)
C1140618 (UMLS 2011AA Property)
C25426 (NCI Thesaurus Property)
C1516050 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
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)
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
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)
SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
Item
SWOG Treating 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)
InformedConsentDateSigned
Item
Date Informed Consent Signed
text
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
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