ID

2490

Description

E1508 Registration Worksheet (step 1) Cisplatin and Etoposide Phosphate With or Without GDC-0449 or Cixutumumab in Treating Patients With Extensive-Stage Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6BDB8EBF-0580-BA81-E040-BB89AD43079B

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6BDB8EBF-0580-BA81-E040-BB89AD43079B

Mots-clés

Téléchargé le

19 septembre 2012

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy

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Lung Cancer NCT00887159 Eligibility - E1508 Registration Worksheet (step 1) - 2898915v1.0

model
Détails

No Instruction available.

1 Formulaires

StudyEvent: E1508 Registration Worksheet (step 1)
1. No Instruction available.

Name

Type

Description | Question | Decode (Coded Value)

Type de données

Alias

Eligibility

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)

EligibilityDeterminationChecklistCompleteEligibilityInd-2

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)

PatientEligibilityIndicator

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)

PatientSignatureConsentInd-2

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)

HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

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)

PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

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.5

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)

PersonTissueSpecimenSubmissionConsentIndicator

Item

I agree my tissue will be submitted for research.

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C12801 (NCI Thesaurus Property)
C0040300 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)

CL.6

Code List

I agree my tissue will be submitted for research.

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

PersonSpecimenMalignantNeoplasmResearchConsentInd-2

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)

SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

Item

My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and 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 research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

PatientContactConsentInd-3

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)
C67527 (NCI Thesaurus Property)
C0016884 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C16452 (NCI Thesaurus Property)
C0009452 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (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)

Demographic Data Required For Patient Registration

Item Group

Patient Demographics / Pre-treatment Characteristics

PatientSexCode

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)

PatientRaceCategory

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)

PatientEthnicGroupCategory

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)

PatientInternationalPaymentType

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)

PatientAddressCountryCode

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)

I have reviewed the above data and agree the date are accurate and correct

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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