ID

24296

Description

Multiple Myeloma and Plasma Cell Neoplasm NCT00644228 Registration - Southwest Oncology Group S0777 Registration Worksheet (Step 2) - Not for OPEN - 2697459v1.0 Southwest Oncology Group S0777 Registration Worksheet (Step 2) - Not for OPEN Lenalidomide and Dexamethasone With or Without Bortezomib in Treating Patients With Previously Untreated Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3EFE9110-F3B6-20FE-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3EFE9110-F3B6-20FE-E044-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/29/17 7/29/17 - Martin Dugas
Uploaded on

July 29, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Multiple Myeloma Lenalidomide Bortezomib NCT00644228 SWOG S0777

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group S0777 Registration Worksheet (Step 2) - Not for OPEN
    1. No Instruction available.
Protocol Information
Description

Protocol Information

Alias
UMLS CUI-1
C1507394
Activation Date
Description

ClinicalStudyProtocolAmendmentActivationDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C64382
NCI Thesaurus Property-2
C41200
UMLS CUI [1]
C1515882
Last Amended Date
Description

DataAmendedLastDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
NCI Thesaurus ValueDomain-2
C25551
UMLS CUI [1,1]
C0680532
UMLS CUI [1,2]
C0011008
Registration Step
Description

RegistrationStepNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25646
NCI Thesaurus Property
C16154
NCI Thesaurus ValueDomain-2
C16154
UMLS CUI [1]
C1514821
For SWOG Institutions
Description

For SWOG Institutions

Alias
UMLS CUI-1
C1519429
Registrar's SWOG Roster ID Number
Description

RegistrarSouthwestOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
NCI Thesaurus ObjectClass
C25357
UMLS CUI [1,1]
C1519429
UMLS CUI [1,2]
C0600091
SWOG Investigator Number
Description

SouthwestOncologyGroupInvestigatorIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25699
NCI Thesaurus ObjectClass-2
C17089
UMLS CUI [1]
C2986286
SWOG Treating Institution Number
Description

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C25699
NCI Thesaurus ObjectClass-2
C25705
NCI Thesaurus ObjectClass-3
C41206
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25337
UMLS CUI [1]
C0489558
For Non-Swog Institutions
Description

For Non-Swog Institutions

Alias
UMLS CUI-1
C1519429
UMLS CUI-2
C2828389
Registering Group Name
Description

Study Group

Data type

text

Alias
NCI Thesaurus ObjectClass
C25646
NCI Thesaurus Property
C43359
NCI Thesaurus ValueDomain
C42614
UMLS CUI [1]
C1320290
Investigator Name
Description

Investigator Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C17089
UMLS CUI [1]
C2826892
Institution Name
Description

InstitutionName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1,1]
C1301943
NCI Institution Number
Description

NCIInstitutionIdentifierCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C19202
UMLS CUI [1]
C0489558
Participating Group Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
Patient Information
Description

Patient Information

Alias
UMLS CUI-1
C1955348
SWOG Patient ID Status
Description

PatientSouthwestOncologyGroupIdentifierStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
NCI Thesaurus ValueDomain
C25688
UMLS CUI [1,1]
C1519429
UMLS CUI [1,2]
C0449438
SWOG Patient ID
Description

PatientSouthwestOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1519429
Projected Start Date of Treatment
Description

TreatmentProjectedBeginDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25631
NCI Thesaurus Property
C25431
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI [1,1]
C3173309
Method of Payment
Description

Patient Payment Type

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25371
UMLS CUI [1]
C0680264
Other, specify
Description

Patient Payment

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25371
UMLS CUI [1]
C0680264
Patient Eligibility
Description

Patient Eligibility

Alias
UMLS CUI-1
C1302261
Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
Description

SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C25699
NCI Thesaurus Property
C25646
NCI Thesaurus Property-2
C25171
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C1302261
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
Assigned Treatment Arm
Description

Treatment Arm

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C32141
NCI Thesaurus ObjectClass
C15368
UMLS CUI [1]
C1522541
Treatment name
Description

ClinicalTrialProtocolTherapeuticProcedureName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C49236
NCI Thesaurus ValueDomain
C42614
UMLS CUI [1,1]
C2826274
Other Notes
Description

SouthwestOncologyGroupRegistrationConfirmationOtherText

Data type

text

Alias
NCI Thesaurus ObjectClass
C25646
NCI Thesaurus ObjectClass-2
C25699
NCI Thesaurus Property
C25458
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C17649
UMLS CUI [1]
C1534847
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Southwest Oncology Group S0777 Registration Worksheet (Step 2) - Not for OPEN
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Protocol Information
C1507394 (UMLS CUI-1)
Activation Date
Item
Activation Date
date
C25164 (NCI Thesaurus ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C64382 (NCI Thesaurus Property)
C41200 (NCI Thesaurus Property-2)
C1515882 (UMLS CUI [1])
Amended Date
Item
Last Amended Date
date
C25164 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C25551 (NCI Thesaurus ValueDomain-2)
C0680532 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
C1514821 (UMLS CUI [1])
Item Group
For SWOG Institutions
C1519429 (UMLS CUI-1)
SWOG Roster ID
Item
Registrar's SWOG Roster ID Number
text
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25357 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
SWOG Investigator Number
Item
SWOG Investigator Number
text
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C2986286 (UMLS CUI [1])
Institution Number
Item
SWOG Treating Institution Number
text
C25699 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0489558 (UMLS CUI [1])
Item Group
For Non-Swog Institutions
C1519429 (UMLS CUI-1)
C2828389 (UMLS CUI-2)
Study Group
Item
Registering Group Name
text
C25646 (NCI Thesaurus ObjectClass)
C43359 (NCI Thesaurus Property)
C42614 (NCI Thesaurus ValueDomain)
C1320290 (UMLS CUI [1])
Investigator Name
Item
Investigator Name
text
C25191 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2826892 (UMLS CUI [1])
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1,1])
Institution Number
Item
NCI Institution Number
text
C25162 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C19202 (NCI Thesaurus ObjectClass-2)
C0489558 (UMLS CUI [1])
Participating Group Patient ID
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Item Group
Patient Information
C1955348 (UMLS CUI-1)
Item
SWOG Patient ID Status
text
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25688 (NCI Thesaurus ValueDomain)
C1519429 (UMLS CUI [1,1])
C0449438 (UMLS CUI [1,2])
CL.1
Code List
SWOG Patient ID Status
CL Item
New Patient (New patient)
C1313868 (UMLS CUI-1)
(Comment:en)
CL Item
Previous Patient (Previous patient)
C0030705 (UMLS CUI-1)
C0205156 (UMLS CUI-2)
(Comment:en)
SWOG Patient ID
Item
SWOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1,1])
C1519429 (UMLS CUI [1,2])
Projected Start Date of Treatment
Item
Projected Start Date of Treatment
date
C15368 (NCI Thesaurus ObjectClass)
C25631 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI [1,1])
Item
Method of Payment
text
C25284 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS CUI [1])
CL.2
Code List
Method of Payment
CL Item
Private Insurance (Private Insurance)
C3845555 (UMLS CUI-1)
(Comment:en)
CL Item
Veterans Sponsored (Veterans Sponsored)
C0042610 (UMLS CUI-1)
(Comment:en)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS CUI-1)
(Comment:en)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
C0018717 (UMLS CUI-1)
C3845555 (UMLS CUI-2)
(Comment:en)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
C0025071 (UMLS CUI-1)
(Comment:en)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
C0596896 (UMLS CUI-1)
(Comment:en)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS CUI-1)
(Comment:en)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
(Comment:en)
CL Item
Military Or Veterans Sponsored NOS (Military or Veterans)
C3245458 (UMLS CUI-1)
C0042610 (UMLS CUI-2)
(Comment:en)
CL Item
Self Pay (no Insurance) (Self Pay)
C3530213 (UMLS CUI-1)
(Comment:en)
CL Item
No Means Of Payment (no Insurance) (No means of payment)
C0021682 (UMLS CUI-1)
C1518422 (UMLS CUI-2)
(Comment:en)
Patient Payment
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS CUI [1])
Item Group
Patient Eligibility
C1302261 (UMLS CUI-1)
Patient eligible
Item
Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
boolean
C16960 (NCI Thesaurus ObjectClass)
C25699 (NCI Thesaurus ObjectClass-2)
C25646 (NCI Thesaurus Property)
C25171 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI [1])
Item Group
Comments
C0947611 (UMLS CUI-1)
Treatment Arm
Item
Assigned Treatment Arm
text
C25337 (NCI Thesaurus ValueDomain)
C32141 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C1522541 (UMLS CUI [1])
Treatment name
Item
Treatment name
text
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C49236 (NCI Thesaurus ObjectClass-2)
C42614 (NCI Thesaurus ValueDomain)
C2826274 (UMLS CUI [1,1])
Other Notes
Item
Other Notes
text
C25646 (NCI Thesaurus ObjectClass)
C25699 (NCI Thesaurus ObjectClass-2)
C25458 (NCI Thesaurus Property)
C25704 (NCI Thesaurus ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C1534847 (UMLS CUI [1])
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