ID

25010

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 24/08/17 24/08/17 -
Caricato su

24 agosto 2017

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group S0833 Registration Worksheet - Step 4

Inglese

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.

1 moduli  
Header - Protocol Information
Descrizione

Header - Protocol Information

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

ClinicalStudyProtocolAmendmentActivationDate (MM DD YYYY)

Tipo di dati

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
Descrizione

DataAmendedLastDate (MM DD YYYY)

Tipo di dati

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
Descrizione

Registration Number

Tipo di dati

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
Descrizione

SWOG Patient ID

Tipo di dati

text

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

SWOG Institutions

Alias
UMLS CUI-1
C1519429
UMLS CUI-2
C1320722
UMLS CUI-3
C0026764
Registrar's SWOG Roster ID Number
Descrizione

RegistrarSouthwestOncologyGroupIdentifierNumber

Tipo di dati

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
Descrizione

SouthwestOncologyGroupInvestigatorIdentifierNumber

Tipo di dati

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
Descrizione

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Tipo di dati

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
Descrizione

Patient Information

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

Start Date of Treatment

Tipo di dati

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
Descrizione

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?
Descrizione

SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

Tipo di dati

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
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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.

1 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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