ID

24963

Description

S0100 Registration Form-2 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB405CA-6FD5-4176-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB405CA-6FD5-4176-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/23/17 8/23/17 -
Uploaded on

August 23, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Registration - S0100 Registration Form-2 - 2031499v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 Registration Form-2
    1. No Instruction available.
Ccrr Module For S0100 Registration Form-2
Description

Ccrr Module For S0100 Registration Form-2

Alias
UMLS CUI-1
C1514821
UMLS CUI-2
C0023418
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]
C1507394
UMLS CUI [1,3]
C0011008
Last Amended Date
Description

Last Amended Date

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 [1,1]
C2348585
UMLS CUI [1,2]
C1519429
Caller's SWOG Roster ID
Description

Caller's SWOG Roster ID

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

Treating Institution Number

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

date

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

Investigator Number

Data type

text

Alias
UMLS CUI [1,1]
C2986286
UMLS CUI [1,2]
C1519429
IRB Approval Date
Description

IRBApprovalDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Description

Start Date of Treatment

Data type

date

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0808070
Initial induction arm
Description

Initial induction arm

Data type

integer

Alias
UMLS CUI [1,1]
C1522541
UMLS CUI [1,2]
C3179010
Comments
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: S0100 Registration Form-2
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For S0100 Registration Form-2
C1514821 (UMLS CUI-1)
C0023418 (UMLS CUI-2)
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])
C1507394 (UMLS CUI [1,2])
C0011008 (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 [1,1])
C1519429 (UMLS CUI [1,2])
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])
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
date
C0021430 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Number
Item
SWOG Investigator Number
text
C2986286 (UMLS CUI [1,1])
C1519429 (UMLS CUI [1,2])
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
Start Date of Treatment
Item
Projected Start Date of Treatment
date
C0087111 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Item
Initial induction arm
integer
C1522541 (UMLS CUI [1,1])
C3179010 (UMLS CUI [1,2])
CL.1
Code List
Initial induction arm
CL Item
Daunorubicin/vincristine/prednisone/l-asparaginase (1)
CL Item
High Dose Ara-c/mixoxantrone (2)
Notes
Item
Comments
text
C0947611 (UMLS CUI [1])
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