ID

2464

Description

E1A06 Registration Worksheet (Step 1) Melphalan, Prednisone, and Thalidomide or Lenalidomide in Treating Patients With Newly Diagnosed Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510B294D-430D-4275-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510B294D-430D-4275-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/17/21 9/17/21 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Multiple Myeloma and Plasma Cell Neoplasm NCT00602641 Eligibility - E1A06 Registration Worksheet (Step 1) - 2762148v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: E1A06 Registration Worksheet (Step 1)
    1. No Instruction available.
Eligibility
Description

Eligibility

First initial
Description

PatientFirstInitialsName

Data type

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
Description

PatientLastInitialsName

Data type

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
Description

EligibilityDeterminationChecklistCompleteEligibilityInd-2

Data type

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?
Description

PatientEligibilityIndicator

Data type

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
Description

PatientSignatureConsentInd-2

Data type

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
Description

InformedConsentFormSignedDate

Data type

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
Description

HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

Data type

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
Description

PatientSignedDischargeMedicalRecordDate

Data type

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
Age at Registration
Description

PatientRegistrationAgeYearCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25646
UMLS 2011AA Property
C1514821
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
ISS stage
Description

MultipleMyelomaDiseaseStageDiagnosisStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C3242
UMLS 2011AA ObjectClass
C0026764
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus Property
C16899
UMLS 2011AA Property
C1300072
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
Description

PersonAncillaryStudyRegistrationText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25646
UMLS 2011AA Property
C1514821
NCI Thesaurus Property
C16041
UMLS 2011AA Property
C1515980
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
Description

PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

Data type

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.
Description

PersonSpecimenMalignantNeoplasmResearchConsentInd-2

Data type

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 use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
Description

SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

Data type

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 from this institution may contact me in the future to ask me to take part in more research.
Description

PatientAdditionalResearchConsentInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C15319
NCI Thesaurus Property
C25406
UMLS 2011AA Property
C1524062
NCI Thesaurus Property
C25460
UMLS 2011AA Property
C1511481
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Patient Demographics / Pre-treatment Characteristics
Description

Patient Demographics / Pre-treatment Characteristics

Patient's Sex
Description

PatientSexCode

Data type

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)
Description

PatientBirthDate

Data type

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's Race
Description

PatientRaceCategory

Data type

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
Description

AddressPostalCodeIdentifier

Data type

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 Ethnicity
Description

PatientEthnicGroupCategory

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C16564
UMLS 2011AA Property
C0015031
Patient Hospital No.
Description

PatientMedicalRecordNumber

Data type

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
Description

PatientSSNNumber

Data type

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)
Description

PatientInternationalPaymentType

Data type

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
Country of residence
Description

PatientAddressCountryCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25407
UMLS 2011AA Property
C1442065
Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct
Description

I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct

Signature of treating physician
Description

TreatingPhysicianSignatureText

Data type

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
Description

TreatingPhysicianSignatureDate

Data type

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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1 forms
  1. StudyEvent: E1A06 Registration Worksheet (Step 1)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
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)
PatientRegistrationAgeYearCount
Item
Age at Registration
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
ISS stage
text
C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C16899 (NCI Thesaurus Property)
C1300072 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.5
Code List
ISS stage
CL Item
I (I)
CL Item
Ii (II)
CL Item
Iii (III)
PersonAncillaryStudyRegistrationText
Item
If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
C16041 (NCI Thesaurus Property)
C1515980 (UMLS 2011AA Property)
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.6
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.7
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 use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or 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.8
Code List
My specimens may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Someone from this institution may contact me in the future to ask me to take part in more research.
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C25406 (NCI Thesaurus Property)
C1524062 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.9
Code List
Someone from this institution may contact me in the future to ask me to take part in more research.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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.10
Code List
Patient's Sex
CL Item
Male (M)
C20197 (NCI Thesaurus)
C0024554 (UMLS 2011AA)
CL Item
Female (F)
C16576 (NCI Thesaurus)
C0015780 (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's Race
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.11
Code List
Patient's Race
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
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
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 Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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)
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)
Item
Patient Ethnicity
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C16564 (NCI Thesaurus Property)
C0015031 (UMLS 2011AA Property)
CL.12
Code List
Patient Ethnicity
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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.13
Code List
Method of payment (check one)
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
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
Veterans Sponsored (Veterans Sponsored)
CL Item
Self Pay (no Insurance) (Self Pay (No Insurance))
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
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Country of residence
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25407 (NCI Thesaurus Property)
C1442065 (UMLS 2011AA Property)
CL.14
Code List
Country of residence
CL Item
Ascension Island (AC)
CL Item
Andorra (AD)
C16289 (NCI Thesaurus)
C0002838 (UMLS 2011AA)
CL Item
United Arab Emirates (AE)
C17232 (NCI Thesaurus)
C0041698 (UMLS 2011AA)
CL Item
Afghanistan (AF)
C16267 (NCI Thesaurus)
C0001732 (UMLS 2011AA)
CL Item
Antigua And Barbuda (AG)
C16303 (NCI Thesaurus)
C0003354 (UMLS 2011AA)
CL Item
Anguilla (AI)
C20133 (NCI Thesaurus)
C0003353 (UMLS 2011AA)
CL Item
Albania (AL)
CL Item
Armenia (AM)
C16306 (NCI Thesaurus)
C0003798 (UMLS 2011AA)
CL Item
Netherland Antilles (AN)
CL Item
Angola (AO)
C16292 (NCI Thesaurus)
C0003023 (UMLS 2011AA)
CL Item
Antarctica (AQ)
C18007 (NCI Thesaurus)
C0454691 (UMLS 2011AA)
CL Item
Argentina (AR)
C16305 (NCI Thesaurus)
C0003761 (UMLS 2011AA)
CL Item
American Samoa (AS)
C17739 (NCI Thesaurus)
C0242536 (UMLS 2011AA)
CL Item
Austria (AT)
C16312 (NCI Thesaurus)
C0004348 (UMLS 2011AA)
CL Item
Australia (AU)
C16311 (NCI Thesaurus)
C0004340 (UMLS 2011AA)
CL Item
Aruba (AW)
C17884 (NCI Thesaurus)
C0282379 (UMLS 2011AA)
CL Item
Azerbaidjan (AZ)
CL Item
Bosnia-herzegovina (BA)
C16361 (NCI Thesaurus)
C0006036 (UMLS 2011AA)
CL Item
Barbados (BB)
C16324 (NCI Thesaurus)
C0004739 (UMLS 2011AA)
CL Item
Bangladesh (BD)
C16323 (NCI Thesaurus)
C0004732 (UMLS 2011AA)
CL Item
Belgium (BE)
C16329 (NCI Thesaurus)
C0004950 (UMLS 2011AA)
CL Item
Burkina Faso (BF)
C16369 (NCI Thesaurus)
C0006409 (UMLS 2011AA)
CL Item
Bulgaria (BG)
C16368 (NCI Thesaurus)
C0006368 (UMLS 2011AA)
CL Item
Bahrain (BH)
C16322 (NCI Thesaurus)
C0004684 (UMLS 2011AA)
CL Item
Burundi (BI)
C16371 (NCI Thesaurus)
C0006448 (UMLS 2011AA)
CL Item
Benin (BJ)
CL Item
Bermuda (BM)
C16334 (NCI Thesaurus)
C0005126 (UMLS 2011AA)
CL Item
Brunei Darussalam (BN)
C16367 (NCI Thesaurus)
C0006320 (UMLS 2011AA)
CL Item
Bolivia (BO)
C16359 (NCI Thesaurus)
C0005918 (UMLS 2011AA)
CL Item
Brazil (BR)
C16364 (NCI Thesaurus)
C0006137 (UMLS 2011AA)
CL Item
Bahamas (BS)
C16321 (NCI Thesaurus)
C0004683 (UMLS 2011AA)
CL Item
Bhutan (BT)
C16336 (NCI Thesaurus)
C0005341 (UMLS 2011AA)
CL Item
Bouvet Island (BV)
C20104 (NCI Thesaurus)
C1511278 (UMLS 2011AA)
CL Item
Botswana (BW)
C16363 (NCI Thesaurus)
C0006041 (UMLS 2011AA)
CL Item
Belarus (BY)
C16372 (NCI Thesaurus)
C0006539 (UMLS 2011AA)
CL Item
Belize (BZ)
C16331 (NCI Thesaurus)
C0004952 (UMLS 2011AA)
CL Item
Canada (CA)
C16380 (NCI Thesaurus)
C0006823 (UMLS 2011AA)
CL Item
Cocos Isl. (CC)
CL Item
Rep. Dem. Congo (CD)
CL Item
Central African Rep. (CF)
CL Item
Congo (CG)
C16467 (NCI Thesaurus)
C0009738 (UMLS 2011AA)
CL Item
Switzerland (CH)
C17181 (NCI Thesaurus)
C0039021 (UMLS 2011AA)
CL Item
Ivory Coast (CI)
CL Item
Cook Islands (CK)
C16469 (NCI Thesaurus)
C0009956 (UMLS 2011AA)
CL Item
Chile (CL)
CL Item
Cameroon (CM)
C16379 (NCI Thesaurus)
C0006802 (UMLS 2011AA)
CL Item
China (CN)
C16428 (NCI Thesaurus)
C0008115 (UMLS 2011AA)
CL Item
Colombia (CO)
C16449 (NCI Thesaurus)
C0009367 (UMLS 2011AA)
CL Item
Costa Rica (CR)
C16470 (NCI Thesaurus)
C0010182 (UMLS 2011AA)
CL Item
Cuba (CU)
C16477 (NCI Thesaurus)
C0010435 (UMLS 2011AA)
CL Item
Cape Verde (CV)
C16382 (NCI Thesaurus)
C0006893 (UMLS 2011AA)
CL Item
Christmas Island (CX)
C44482 (NCI Thesaurus)
C0006888 (UMLS 2011AA)
CL Item
Cyprus (CY)
C16480 (NCI Thesaurus)
C0010622 (UMLS 2011AA)
CL Item
Czech Republic (CZ)
C17668 (NCI Thesaurus)
C0206578 (UMLS 2011AA)
CL Item
Germany (DE)
CL Item
Djibouti (DJ)
CL Item
Denmark (DK)
CL Item
Dominica (DM)
CL Item
Dominican Republic (DO)
CL Item
Algeria (DZ)
CL Item
Ecuador (EC)
CL Item
Estonia (EE)
CL Item
Egypt (EG)
CL Item
Western Sahara (EH)
CL Item
Eritrea (ER)
CL Item
Spain (ES)
CL Item
Ethiopia (ET)
CL Item
Finland (FI)
CL Item
Fiji (FJ)
CL Item
Falkland Isl. (FK)
CL Item
Micronesia (FM)
CL Item
Faroe Islands (FO)
CL Item
France (FR)
CL Item
France (european Ter.) (FX)
CL Item
Gabon (GA)
CL Item
Great Britain (GB)
CL Item
Grenada (GD)
CL Item
Georgia (GE)
CL Item
Guiana (fr.) (GF)
CL Item
Guernsey (GG)
CL Item
Ghana (GH)
CL Item
Gibraltar (GI)
CL Item
Greenland (GL)
CL Item
Gambia (GM)
CL Item
Guinea (GN)
CL Item
Guadeloupe (fr.) (GP)
CL Item
Equatorial Guinea (GQ)
CL Item
Greece (GR)
CL Item
South Georgia And South Sandwich Islands (GS)
CL Item
Guatemala (GT)
CL Item
Guam (us) (GU)
CL Item
Guinea Bissau (GW)
CL Item
Guyana (GY)
CL Item
Hong Kong (HK)
CL Item
Heard & Mcdonald Isl. (HM)
CL Item
Honduras (HN)
C16694 (NCI Thesaurus)
C0019905 (UMLS 2011AA)
CL Item
Croatia (HR)
C16474 (NCI Thesaurus)
C0010343 (UMLS 2011AA)
CL Item
Haiti (HT)
C16660 (NCI Thesaurus)
C0018510 (UMLS 2011AA)
CL Item
Hungary (HU)
C16699 (NCI Thesaurus)
C0020174 (UMLS 2011AA)
CL Item
Indonesia (ID)
C16728 (NCI Thesaurus)
C0021247 (UMLS 2011AA)
CL Item
Ireland (IE)
C16757 (NCI Thesaurus)
C0022067 (UMLS 2011AA)
CL Item
Israel (IL)
C16760 (NCI Thesaurus)
C0022271 (UMLS 2011AA)
CL Item
Isle Of Man (IM)
C0022132 (NCI Metathesaurus)
CL Item
India (IN)
C16727 (NCI Thesaurus)
C0021201 (UMLS 2011AA)
CL Item
British Indian O. Ter. (IO)
CL Item
Iraq (IQ)
C16756 (NCI Thesaurus)
C0022066 (UMLS 2011AA)
CL Item
Iran (IR)
C16755 (NCI Thesaurus)
C0022065 (UMLS 2011AA)
CL Item
Iceland (IS)
C16704 (NCI Thesaurus)
C0020750 (UMLS 2011AA)
CL Item
Italy (IT)
C16761 (NCI Thesaurus)
C0022277 (UMLS 2011AA)
CL Item
Jersey (JE)
CL Item
Jamaica (JM)
C16763 (NCI Thesaurus)
C0022337 (UMLS 2011AA)
CL Item
Jordan (JO)
C16765 (NCI Thesaurus)
C0022418 (UMLS 2011AA)
CL Item
Japan (JP)
C16764 (NCI Thesaurus)
C0022341 (UMLS 2011AA)
CL Item
Kenya (KE)
C16769 (NCI Thesaurus)
C0022558 (UMLS 2011AA)
CL Item
Kyrgyz Republic (KG)
CL Item
Cambodia (KH)
C16378 (NCI Thesaurus)
C0006797 (UMLS 2011AA)
CL Item
Kiribati (KI)
C16639 (NCI Thesaurus)
C0017550 (UMLS 2011AA)
CL Item
Comoros (KM)
C16458 (NCI Thesaurus)
C0009490 (UMLS 2011AA)
CL Item
St. Kitts Nevis Anguilla (KN)
CL Item
Korea (north) (KP)
CL Item
Korea (south) (KR)
CL Item
Kuwait (KW)
C16775 (NCI Thesaurus)
C0022804 (UMLS 2011AA)
CL Item
Cayman Islands (KY)
C16391 (NCI Thesaurus)
C0007481 (UMLS 2011AA)
CL Item
Kazakstan (KZ)
CL Item
Laos (LA)
CL Item
Lebanon (LB)
C16784 (NCI Thesaurus)
C0023190 (UMLS 2011AA)
CL Item
Saint Lucia (LC)
C17113 (NCI Thesaurus)
C0036056 (UMLS 2011AA)
CL Item
Liechtenstein (LI)
C16794 (NCI Thesaurus)
C0023668 (UMLS 2011AA)
CL Item
Sri Lanka (LK)
C17163 (NCI Thesaurus)
C0038088 (UMLS 2011AA)
CL Item
Liberia (LR)
C16791 (NCI Thesaurus)
C0023617 (UMLS 2011AA)
CL Item
Lesotho (LS)
CL Item
Lithuania (LT)
C16799 (NCI Thesaurus)
C0023879 (UMLS 2011AA)
CL Item
Luxembourg (LU)
C16803 (NCI Thesaurus)
C0024176 (UMLS 2011AA)
CL Item
Latvia (LV)
C16783 (NCI Thesaurus)
C0023128 (UMLS 2011AA)
CL Item
Libya (LY)
CL Item
Morocco (MA)
C16878 (NCI Thesaurus)
C0026544 (UMLS 2011AA)
CL Item
Monaco (MC)
C16874 (NCI Thesaurus)
C0026405 (UMLS 2011AA)
CL Item
Moldova (MD)
C16871 (NCI Thesaurus)
C0026374 (UMLS 2011AA)
CL Item
Madagascar (MG)
C16808 (NCI Thesaurus)
C0024443 (UMLS 2011AA)
CL Item
Marshall Islands (MH)
C16822 (NCI Thesaurus)
C0024851 (UMLS 2011AA)
CL Item
Macedonia (MK)
C0700290 (NCI Metathesaurus)
CL Item
Mali (ML)
C16816 (NCI Thesaurus)
C0024581 (UMLS 2011AA)
CL Item
Myanmar (MM)
C16370 (NCI Thesaurus)
C0006416 (UMLS 2011AA)
CL Item
Mongolia (MN)
C16875 (NCI Thesaurus)
C0026410 (UMLS 2011AA)
CL Item
Macau (MO)
C16807 (NCI Thesaurus)
C0024403 (UMLS 2011AA)
CL Item
Northern Mariana Isl. (MP)
CL Item
Martinique (fr.) (MQ)
CL Item
Mauritania (MR)
C16826 (NCI Thesaurus)
C0024943 (UMLS 2011AA)
CL Item
Montserrat (MS)
C16876 (NCI Thesaurus)
C0026514 (UMLS 2011AA)
CL Item
Malta (MT)
C16817 (NCI Thesaurus)
C0024653 (UMLS 2011AA)
CL Item
Mauritius (MU)
C16827 (NCI Thesaurus)
C0024944 (UMLS 2011AA)
CL Item
Maldives (MV)
C16815 (NCI Thesaurus)
C0024553 (UMLS 2011AA)
CL Item
Malawi (MW)
C16813 (NCI Thesaurus)
C0024548 (UMLS 2011AA)
CL Item
Mexico (MX)
C16850 (NCI Thesaurus)
C0025885 (UMLS 2011AA)
CL Item
Malaysia (MY)
C16814 (NCI Thesaurus)
C0024552 (UMLS 2011AA)
CL Item
Mozambique (MZ)
C16882 (NCI Thesaurus)
C0026655 (UMLS 2011AA)
CL Item
Namibia (NA)
C16891 (NCI Thesaurus)
C0027366 (UMLS 2011AA)
CL Item
New Caledonia (fr.) (NC)
CL Item
Niger (NE)
C16916 (NCI Thesaurus)
C0028074 (UMLS 2011AA)
CL Item
Norfolk Island (NF)
C16919 (NCI Thesaurus)
C0028366 (UMLS 2011AA)
CL Item
Nigeria (NG)
C16917 (NCI Thesaurus)
C0028075 (UMLS 2011AA)
CL Item
Nicaragua (NI)
C16915 (NCI Thesaurus)
C0028002 (UMLS 2011AA)
CL Item
Netherlands (NL)
C16903 (NCI Thesaurus)
C0027778 (UMLS 2011AA)
CL Item
Norway (NO)
C16920 (NCI Thesaurus)
C0028423 (UMLS 2011AA)
CL Item
Nepal (NP)
C16901 (NCI Thesaurus)
C0027689 (UMLS 2011AA)
CL Item
Nauru (NR)
C16896 (NCI Thesaurus)
C0027496 (UMLS 2011AA)
CL Item
Niue (NU)
C16918 (NCI Thesaurus)
C0028219 (UMLS 2011AA)
CL Item
New Zealand (NZ)
C16914 (NCI Thesaurus)
C0027978 (UMLS 2011AA)
CL Item
Oman (OM)
C16933 (NCI Thesaurus)
C0028971 (UMLS 2011AA)
CL Item
Other (Other)
CL Item
Panama (PA)
C16951 (NCI Thesaurus)
C0030266 (UMLS 2011AA)
CL Item
Peru (PE)
C16972 (NCI Thesaurus)
C0031238 (UMLS 2011AA)
CL Item
Polynesia (fr.) (PF)
CL Item
Papua New Guinea (PG)
C16952 (NCI Thesaurus)
C0030375 (UMLS 2011AA)
CL Item
Philippines (PH)
CL Item
Pakistan (PK)
C16949 (NCI Thesaurus)
C0030211 (UMLS 2011AA)
CL Item
Poland (PL)
C17002 (NCI Thesaurus)
C0032356 (UMLS 2011AA)
CL Item
St. Pierre & Miquelon (PM)
CL Item
Pitcairn (PN)
C16993 (NCI Thesaurus)
C0031995 (UMLS 2011AA)
CL Item
Puerto Rico (PR)
C17043 (NCI Thesaurus)
C0034044 (UMLS 2011AA)
CL Item
Portugal (PT)
C17006 (NCI Thesaurus)
C0032729 (UMLS 2011AA)
CL Item
Palau (PW)
C17733 (NCI Thesaurus)
C0242397 (UMLS 2011AA)
CL Item
Paraguay (PY)
C16953 (NCI Thesaurus)
C0030428 (UMLS 2011AA)
CL Item
Qatar (QA)
C17045 (NCI Thesaurus)
C0034366 (UMLS 2011AA)
CL Item
Reunion (fr.) (RE)
CL Item
Romania (RO)
C17108 (NCI Thesaurus)
C0035826 (UMLS 2011AA)
CL Item
Russian Federation (RU)
CL Item
Rwanda (RW)
C17112 (NCI Thesaurus)
C0035978 (UMLS 2011AA)
CL Item
Saudi Arabia (SA)
C17117 (NCI Thesaurus)
C0036243 (UMLS 2011AA)
CL Item
Solomon Islands (SB)
C17148 (NCI Thesaurus)
C0037623 (UMLS 2011AA)
CL Item
Seychelles (SC)
C17129 (NCI Thesaurus)
C0036919 (UMLS 2011AA)
CL Item
Sudan (SD)
C17170 (NCI Thesaurus)
C0038642 (UMLS 2011AA)
CL Item
Sweden (SE)
C17180 (NCI Thesaurus)
C0038995 (UMLS 2011AA)
CL Item
Singapore (SG)
C17134 (NCI Thesaurus)
C0037173 (UMLS 2011AA)
CL Item
St. Helena (SH)
CL Item
Slovenia (SI)
C17138 (NCI Thesaurus)
C0037334 (UMLS 2011AA)
CL Item
Svalbard & Jan Mayen Isl. (SJ)
CL Item
Slovakia (SK)
C17669 (NCI Thesaurus)
C0206579 (UMLS 2011AA)
CL Item
Sierra Leone (SL)
C17130 (NCI Thesaurus)
C0037063 (UMLS 2011AA)
CL Item
San Marino (SM)
C17115 (NCI Thesaurus)
C0036154 (UMLS 2011AA)
CL Item
Senegal (SN)
C17121 (NCI Thesaurus)
C0036644 (UMLS 2011AA)
CL Item
Somalia (SO)
C17149 (NCI Thesaurus)
C0037640 (UMLS 2011AA)
CL Item
Suriname (SR)
C17175 (NCI Thesaurus)
C0038944 (UMLS 2011AA)
CL Item
St. Tome And Principe (ST)
CL Item
Soviet Union (SU)
CL Item
El Salvador (SV)
C16532 (NCI Thesaurus)
C0013754 (UMLS 2011AA)
CL Item
Syria (SY)
C17182 (NCI Thesaurus)
C0039138 (UMLS 2011AA)
CL Item
Swaziland (SZ)
C17179 (NCI Thesaurus)
C0038983 (UMLS 2011AA)
CL Item
Turks & Caicos Islands (TC)
CL Item
Chad (TD)
C16412 (NCI Thesaurus)
C0007928 (UMLS 2011AA)
CL Item
French Southern Terr. (TF)
CL Item
Togo (TG)
C17202 (NCI Thesaurus)
C0040363 (UMLS 2011AA)
CL Item
Thailand (TH)
C17192 (NCI Thesaurus)
C0039725 (UMLS 2011AA)
CL Item
Tadjikistan (TJ)
CL Item
Tokelau (TK)
C17704 (NCI Thesaurus)
C0220928 (UMLS 2011AA)
CL Item
Turkmenistan (TM)
C17223 (NCI Thesaurus)
C0041403 (UMLS 2011AA)
CL Item
Tunisia (TN)
C17221 (NCI Thesaurus)
C0041388 (UMLS 2011AA)
CL Item
Tonga (TO)
CL Item
East Timor (TP)
C17200 (NCI Thesaurus)
C1452561 (UMLS 2011AA)
CL Item
Turkey (TR)
C17222 (NCI Thesaurus)
C0041400 (UMLS 2011AA)
CL Item
Trinidad & Tobago (TT)
CL Item
Tuvalu (TV)
C17225 (NCI Thesaurus)
C0041413 (UMLS 2011AA)
CL Item
Taiwan (TW)
C17184 (NCI Thesaurus)
C0039260 (UMLS 2011AA)
CL Item
Tanzania (TZ)
C17185 (NCI Thesaurus)
C0039298 (UMLS 2011AA)
CL Item
Ukraine (UA)
C17229 (NCI Thesaurus)
C0041580 (UMLS 2011AA)
CL Item
Uganda (UG)
C17228 (NCI Thesaurus)
C0041573 (UMLS 2011AA)
CL Item
United Kingdom (UK)
C17233 (NCI Thesaurus)
C0041700 (UMLS 2011AA)
CL Item
Us Minor Outlying Isl. (UM)
CL Item
Usa (US)
CL Item
Uruguay (UY)
C17244 (NCI Thesaurus)
C0042113 (UMLS 2011AA)
CL Item
Uzbekistan (UZ)
C17246 (NCI Thesaurus)
C0042177 (UMLS 2011AA)
CL Item
Vatican City State (VA)
CL Item
St. Vincent & Grenadines (VC)
CL Item
Venezuela (VE)
C17250 (NCI Thesaurus)
C0042469 (UMLS 2011AA)
CL Item
Virgin Islands (brit) (VG)
CL Item
Virgin Islands (us) (VI)
CL Item
Vietnam (VN)
C17252 (NCI Thesaurus)
C0042658 (UMLS 2011AA)
CL Item
Vanuatu (VU)
C17247 (NCI Thesaurus)
C0042321 (UMLS 2011AA)
CL Item
Wallis & Futuna Islands (WF)
CL Item
Western Samoa (WS)
CL Item
Yemen (YE)
C17264 (NCI Thesaurus)
C0043402 (UMLS 2011AA)
CL Item
Mayotte (YT)
C16828 (NCI Thesaurus)
C0024974 (UMLS 2011AA)
CL Item
Yugoslavia (YU)
CL Item
South Africa (ZA)
CL Item
Zambia (ZM)
C17267 (NCI Thesaurus)
C0043445 (UMLS 2011AA)
CL Item
Dem. Rep. Of Congo (ZR)
CL Item
Zimbabwe (ZW)
C17268 (NCI Thesaurus)
C0043476 (UMLS 2011AA)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item Group
I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct
TreatingPhysicianSignatureText
Item
Signature of treating physician
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
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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