No Instruction available.

1 forms

StudyEvent: Southwest Oncology Group Registration Form
1. No Instruction available.

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Unnamed 1

Item Group

Unnamed 1

SWOGStudyNo.

Item

SWOG Study No.

text

RegistrationStep

Item

Registration Step

text

TreatmentArmNumber

Item

Assigned Treatment Arm

text

ActivationDate

Item

Activation Date

text

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)

Unnamed 2

Item Group

Unnamed 2

Patient'sName

Item

Patient's Name

text

SWOGPatientID

Item

SWOG Patient ID

text

Unnamed 3

Item Group

Unnamed 3

Unnamed 4

Item Group

Unnamed 4

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

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

SouthwestOncologyGroupInvestigatorIdentifierNumber

Item

SWOG Investigator Number

double

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (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)

ProjectedTreatmentBeginDate

Item

Projected Start Date of Treatment (Patient Consent for Specimen Use)

date

PatientInitialConsent,Specimen,Patient'scancerresearchInd

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)

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Item

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

text

CL.2

Code List

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

CL Item

Null (Yes)

CL Item

Null (No)

PatientInitialConsent,Specimen,ContactInd

Item

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

CL Item

Null (Yes)

CL Item

Null (No)

Unnamed 5

Item Group

Unnamed 5

PatientBirthDate

Item

Patient's Date of Birth

date

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

PatientGender

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)

PaymentMethod

Item

Method of Payment

text

CL.5

Code List

Method of Payment

CL Item

Private (Private)

CL Item

Medicare (Medicare)

CL Item

Medicare and Private (Medicare and Private)

CL Item

Medicaid (Medicaid)

CL Item

Medicaid and Medicare (Medicaid and Medicare)

CL Item

No insurance (self-pay) (No insurance (self-pay))

CL Item

No insurance (no means) (No insurance (no means))

CL Item

Other, specify at registration (Other, specify at registration)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Veterans Admin (Veterans Admin)

CL Item

Military (Military)

Patient'sEthnicity

Item

Patient's Ethnicity

text

CL.6

Code List

Patient's Ethnicity

CL Item

Unknown2006635 (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

No_not_spanish2006636 (No (not Spanish))

CL Item

Yes_mexican2006637 (Yes, Mexican)

CL Item

Yes_puerto_rican2006638 (Yes, Puerto Rican)

CL Item

Yes_cuban2006639 (Yes, Cuban)

CL Item

Yes_central_american2006640 (Yes, Central American)

CL Item

Yes_south_american2006641 (Yes, South American)

CL Item

Yes_other2006642 (Yes, Other)

CL Item

Yes_nos2006643 (Yes, NOS)

PatientRace

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, Specify (Other, Specify)

Other,specify(patient'srace)

Item

Other, specify (patient's race) (If a U.S. resident)

text

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 (Statification Factors)

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)

StageGrouping

Item

Stage

text

CL.8

Code List

Stage

CL Item

Iiib (not Recurrent) (IIIB)

CL Item

Iv (not Recurrent) (IV)

LDH