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ID

25010

Description

Southwest Oncology Group S0833 Registration Worksheet - Step 4 Bortezomib, Thalidomide, Lenalidomide, Combination Chemotherapy, and Autologous Stem Cell Transplant in Treating Patients With Newly Diagnosed Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9BB42DBE-F212-F266-E040-BB89AD434D67

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9BB42DBE-F212-F266-E040-BB89AD434D67

Keywords

  1. 9/19/12 9/19/12 -
  2. 8/24/17 8/24/17 -
Uploaded on

August 24, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    Southwest Oncology Group S0833 Registration Worksheet - Step 4

    INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.

    Header - Protocol Information
    Description

    Header - Protocol Information

    Alias
    UMLS CUI-1
    C1507394
    UMLS CUI-2
    C0026764
    Activation Date
    Description

    ClinicalStudyProtocolAmendmentActivationDate (MM DD YYYY)

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    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

    DataAmendedLastDate (MM DD YYYY)

    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
    Registration Step
    Description

    Registration Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C25646
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    UMLS CUI [1,1]
    C1514821
    UMLS CUI [1,2]
    C0237753
    SWOG Patient ID
    Description

    SWOG Patient ID

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C2348585
    UMLS CUI [1,2]
    C1519429
    SWOG Institutions
    Description

    SWOG Institutions

    Alias
    UMLS CUI-1
    C1519429
    UMLS CUI-2
    C1320722
    UMLS CUI-3
    C0026764
    Registrar's SWOG Roster ID Number
    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]
    C0557514
    UMLS CUI [1,2]
    C0237753
    UMLS CUI [1,3]
    C0600091
    UMLS CUI [1,4]
    C1519429
    SWOG Investigator Number
    Description

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C25699
    NCI Thesaurus ObjectClass-2
    C17089
    UMLS CUI [1,1]
    C2986286
    UMLS CUI [1,2]
    C1519429
    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]
    C1272753
    UMLS CUI [1,2]
    C1519429
    UMLS CUI [1,3]
    C0600091
    Patient Information
    Description

    Patient Information

    Alias
    UMLS CUI-1
    C1955348
    UMLS CUI-2
    C0087111
    UMLS CUI-3
    C0026764
    Projected Start Date of Treatment
    Description

    Start Date of Treatment

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C25631
    NCI Thesaurus Property
    C25431
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS CUI [1,1]
    C0087111
    UMLS CUI [1,2]
    C0808070
    Patient Eligibility
    Description

    Patient Eligibility

    Alias
    UMLS CUI-1
    C1516637
    UMLS CUI-2
    C0013893
    UMLS CUI-3
    C0026764
    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
    Description

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ObjectClass-2
    C25699
    NCI Thesaurus Property
    C25646
    NCI Thesaurus Property-2
    C25171
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI [1]
    C0013893
    UMLS CUI [2,1]
    C1514821
    UMLS CUI [2,2]
    C1519429

    Similar models

    INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header - Protocol Information
    C1507394 (UMLS CUI-1)
    C0026764 (UMLS CUI-2)
    Activation Date
    Item
    Activation Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    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])
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    C1514821 (UMLS CUI [1,1])
    C0237753 (UMLS CUI [1,2])
    SWOG Patient ID
    Item
    SWOG Patient ID
    text
    C2348585 (UMLS CUI [1,1])
    C1519429 (UMLS CUI [1,2])
    Item Group
    SWOG Institutions
    C1519429 (UMLS CUI-1)
    C1320722 (UMLS CUI-2)
    C0026764 (UMLS CUI-3)
    Registrar's SWOG Roster ID Number
    Item
    Registrar's SWOG Roster ID Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS CUI [1,1])
    C0237753 (UMLS CUI [1,2])
    C0600091 (UMLS CUI [1,3])
    C1519429 (UMLS CUI [1,4])
    SWOG Investigator Number
    Item
    SWOG Investigator Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus ObjectClass)
    C17089 (NCI Thesaurus ObjectClass-2)
    C2986286 (UMLS CUI [1,1])
    C1519429 (UMLS CUI [1,2])
    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)
    C1272753 (UMLS CUI [1,1])
    C1519429 (UMLS CUI [1,2])
    C0600091 (UMLS CUI [1,3])
    Item Group
    Patient Information
    C1955348 (UMLS CUI-1)
    C0087111 (UMLS CUI-2)
    C0026764 (UMLS CUI-3)
    Start Date of Treatment
    Item
    Projected Start Date of Treatment
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25631 (NCI Thesaurus ObjectClass-2)
    C25431 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C0087111 (UMLS CUI [1,1])
    C0808070 (UMLS CUI [1,2])
    Item Group
    Patient Eligibility
    C1516637 (UMLS CUI-1)
    C0013893 (UMLS CUI-2)
    C0026764 (UMLS CUI-3)
    Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
    Item
    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C25646 (NCI Thesaurus Property)
    C25171 (NCI Thesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C0013893 (UMLS CUI [1])
    C1514821 (UMLS CUI [2,1])
    C1519429 (UMLS CUI [2,2])

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