ID

24873

Description

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

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/21/17 8/21/17 -
Uploaded on

August 21, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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S0100 Registration Form-1

English

No Instruction available.

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

Patient Consent For Specimen Use

Alias
UMLS CUI-1
C0370003
UMLS CUI-2
C0021430
UMLS CUI-3
C0035168
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
Description

tissue for research

Data type

boolean

Alias
UMLS CUI [1,1]
C0370003
UMLS CUI [1,2]
C0035168
Patient's tissue may be kept for research about other health problems
Description

tissue for research

Data type

boolean

Alias
UMLS CUI [1,1]
C0370003
UMLS CUI [1,2]
C0035168
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
Description

contact patient

Data type

boolean

Alias
UMLS CUI [1,1]
C0332158
UMLS CUI [1,2]
C0030705
Patient's Date of Birth
Description

Birth Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25275
UMLS CUI [1]
C0421451
Patient's Sex
Description

Patient Gender

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17357
UMLS CUI [1]
C0079399
Method of Payment
Description

PaymentMethod

Data type

text

Patient's Ethnicity
Description

Patient Ethnicity

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
UMLS CUI [1]
C0015031
Patient's Race
Description

Patient Race

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
UMLS CUI [1]
C0034510
specify
Description

Race Other

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1,1]
C0034510
UMLS CUI [1,2]
C0205394
Patient's Social Security Number
Description

Patient's Social Security Number

Data type

text

Alias
UMLS CUI [1]
C1301821
Patient's ZIP Code
Description

Patient's ZIP Code

Data type

integer

Alias
UMLS CUI [1]
C0421454
Country of Residence, if not USA
Description

Country of Residence

Data type

text

Alias
UMLS CUI [1]
C1562954
Social Insurance Number
Description

PatientSocialInsuranceIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C62650
NCI Thesaurus ObjectClass-3
C16745
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25337
UMLS CUI [1,1]
C0728831
UMLS CUI [1,2]
C0021672
UMLS CUI [1,3]
C0600091
Postal Code
Description

Postal Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ObjectClass
C25407
NCI Thesaurus Property
C25621
UMLS CUI [1]
C1514254
Stratification Factors
Description

Stratification Factors

Alias
UMLS CUI-1
C1514984
Age
Description

Patient Age

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25150
UMLS CUI [1]
C0001779
Phenotype
Description

Phenotype

Data type

integer

Alias
UMLS CUI [1,1]
C0031437
UMLS CUI [1,2]
C1961099
UMLS CUI [1,3]
C1292769
Notes
Description

Comments

Data type

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1514984
Ccrr Module For S0100 Registration Form-1
Description

Ccrr Module For S0100 Registration Form-1

Alias
UMLS CUI-1
C1514821
SWOG Study No.
Description

Study Number

Data type

text

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0600091
Registration Step
Description

Registration Step

Data type

text

Alias
UMLS CUI-1
C1514821
Assigned Treatment Arm
Description

Protocol Treatment Arm

Data type

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C42651
NCI Thesaurus Property
C32141
NCI Thesaurus Property-2
C25426
NCI Thesaurus ValueDomain
C25704
UMLS CUI [1]
C1522541
Activation Date
Description

Activation Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C64382
NCI Thesaurus Property-2
C41200
UMLS CUI [1,1]
C1879547
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1507394
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]
C1691222
UMLS CUI [1,2]
C1517741
UMLS CUI [1,3]
C0011008
Patient's Name
Description

Patient's Name

Data type

text

Alias
UMLS CUI [1]
C1299487
SWOG Patient ID
Description

Patient ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Caller's SWOG Roster ID
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]
C0237753
UMLS CUI [1,3]
C0600091
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 [1,1]
C1519429
UMLS CUI [1,2]
C1272753
UMLS CUI [1,3]
C0600091
Date Informed Consent Signed
Description

Date Informed Consent Signed

Data type

text

Alias
UMLS CUI [1,1]
C0021430
UMLS CUI [1,2]
C0011008
SWOG Investigator Number
Description

Investigator

Data type

text

Alias
UMLS CUI [1,1]
C2826892
UMLS CUI [1,2]
C0600091
IRB Approval Date
Description

IRB Approval Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25425
UMLS CUI [1,1]
C1507394
UMLS CUI [1,2]
C0205540
UMLS CUI [1,3]
C0011008
Projected Start Date of Treatment
Description

Projected Start Date of Treatment

Data type

date

Alias
UMLS CUI [1]
C3173309
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: S0100 Registration Form-1
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Consent For Specimen Use
C0370003 (UMLS CUI-1)
C0021430 (UMLS CUI-2)
C0035168 (UMLS CUI-3)
tissue for research
Item
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
boolean
C0370003 (UMLS CUI [1,1])
C0035168 (UMLS CUI [1,2])
tissue for research
Item
Patient's tissue may be kept for research about other health problems
boolean
C0370003 (UMLS CUI [1,1])
C0035168 (UMLS CUI [1,2])
contact patient
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.
boolean
C0332158 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
Birth Date
Item
Patient's Date of Birth
date
C16960 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0421451 (UMLS CUI [1])
Item
Patient's Sex
integer
C25372 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI [1])
CL.4
Code List
Patient's Sex
CL Item
Female (1)
CL Item
Male (2)
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
integer
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0015031 (UMLS CUI [1])
CL.6
Code List
Patient's Ethnicity
CL Item
Unknown (1)
C0439673 (UMLS CUI-1)
(Comment:en)
CL Item
No (not Spanish) (2)
(Comment:en)
CL Item
Yes, Mexican (3)
(Comment:en)
CL Item
Yes,Puerto Rican (4)
(Comment:en)
CL Item
Yes, Cuban (5)
(Comment:en)
CL Item
Yes, Central American (6)
(Comment:en)
CL Item
Yes, South American (7)
(Comment:en)
CL Item
Yes,Other (8)
(Comment:en)
CL Item
Yes, NOS (9)
(Comment:en)
CL Item
Hispanic_or_latino (10)
(Comment:en)
CL Item
Non_hispanic (11)
(Comment:en)
Item
Patient's Race
text
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS CUI [1])
CL.7
Code List
Patient's Race
CL Item
White or Caucasian (1)
(Comment:en)
CL Item
Black or African American (2)
(Comment:en)
CL Item
Native Hawaiian or Other Pacific Islander (3)
(Comment:en)
CL Item
Asian (4)
(Comment:en)
CL Item
American Indian or Alaska Native (5)
(Comment:en)
CL Item
Unknown (6)
C0439673 (UMLS CUI-1)
(Comment:en)
CL Item
Other (7)
(Comment:en)
Race Other
Item
specify
text
C25685 (NCI Thesaurus ValueDomain)
C0034510 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Patient's Social Security Number
Item
Patient's Social Security Number
text
C1301821 (UMLS CUI [1])
Patient's ZIP Code
Item
Patient's ZIP Code
integer
C0421454 (UMLS CUI [1])
Country of Residence
Item
Country of Residence, if not USA
text
C1562954 (UMLS CUI [1])
Social Insurance Number
Item
Social Insurance Number
text
C16960 (NCI Thesaurus ObjectClass)
C62650 (NCI Thesaurus ObjectClass-2)
C16745 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0728831 (UMLS CUI [1,1])
C0021672 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Postal Code
Item
Postal Code
text
C25162 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS CUI [1])
Item Group
Stratification Factors
C1514984 (UMLS CUI-1)
Patient Age
Item
Age
float
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS CUI [1])
Item
Phenotype
integer
C0031437 (UMLS CUI [1,1])
C1961099 (UMLS CUI [1,2])
C1292769 (UMLS CUI [1,3])
CL.9
Code List
Phenotype
CL Item
T-cell (1)
CL Item
Pre-b (2)
Comments
Item
Notes
text
C0947611 (UMLS CUI [1,1])
C1514984 (UMLS CUI [1,2])
Item Group
Ccrr Module For S0100 Registration Form-1
C1514821 (UMLS CUI-1)
Study Number
Item
SWOG Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI-1)
Protocol Treatment Arm
Item
Assigned Treatment Arm
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C32141 (NCI Thesaurus Property)
C25426 (NCI Thesaurus Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1522541 (UMLS CUI [1])
Activation Date
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C64382 (NCI Thesaurus Property)
C41200 (NCI Thesaurus Property-2)
C1879547 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1507394 (UMLS CUI [1,3])
Last Amended Date
Item
Last Amended Date
date
C25164 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C25551 (NCI Thesaurus ValueDomain-2)
C1691222 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Patient's Name
Item
Patient's Name
text
C1299487 (UMLS CUI [1])
Patient ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Caller's SWOG Roster ID
Item
Caller's SWOG Roster ID
text
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25357 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
SWOG Treating 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)
C1519429 (UMLS CUI [1,1])
C1272753 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Date Informed Consent Signed
Item
Date Informed Consent Signed
text
C0021430 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator
Item
SWOG Investigator Number
text
C2826892 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
IRB Approval Date
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C25425 (NCI Thesaurus Property)
C1507394 (UMLS CUI [1,1])
C0205540 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Projected Start Date of Treatment
Item
Projected Start Date of Treatment
date
C3173309 (UMLS CUI [1])
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