ID

24882

Description

S0100 Registration Form-4 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40AD7-35D8-4185-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40AD7-35D8-4185-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/22/17 8/22/17 -
Uploaded on

August 22, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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S0100 Registration Form-4

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 Registration Form-4
    1. No Instruction available.
Ccrr Module For S0100 Registration Form-4
Description

Ccrr Module For S0100 Registration Form-4

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
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
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

integer

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

date

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

Investigator Number

Data type

text

Alias
UMLS CUI [1]
C2826689
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

Start Date of Treatment

Data type

date

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0808070
Candidate for allogeneic PBSCT?
Description

allogeneic PBSCT

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1]
C2242529
Comments
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: S0100 Registration Form-4
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For S0100 Registration Form-4
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])
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)
C0680532 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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
integer
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
date
C0021430 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Number
Item
SWOG Investigator Number
text
C2826689 (UMLS CUI [1])
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])
Start Date of Treatment
Item
Projected Start Date of Treatment
date
C0087111 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
allogeneic PBSCT
Item
Candidate for allogeneic PBSCT?
boolean
C25180 (NCI Thesaurus ValueDomain)
C2242529 (UMLS CUI [1])
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
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