ID

25153

Description

S1001 Registration Worksheet Step 2 PET-Directed Therapy in Treating Patients With Limited-Stage Diffuse Large B-Cell Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55DBEC7-1F59-3244-E040-BB89AD43434F

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55DBEC7-1F59-3244-E040-BB89AD43434F

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 28/08/2017 28/08/2017 -
Téléchargé le

28 août 2017

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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S1001 Registration Worksheet Step 2

Anglais

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 Formulaires  
Protocol Information
Description

Protocol Information

Alias
UMLS CUI-1
C1507394
UMLS CUI-2
C0079744
Activation Date
Description

ClinicalStudyProtocolAmendmentActivationDate (MM DD YYYY)

Type de données

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)

Type de données

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

Type de données

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

Type de données

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1519429
Swog Patient Id
Description

Swog Patient Id

SWOG Patient ID
Description

Trial subject ID SWOG

Type de données

float

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25699
UMLS CUI-1
C2348585
UMLS CUI-2
C1519429
SWOG Institutions
Description

SWOG Institutions

Alias
UMLS CUI-1
C1519429
UMLS CUI-2
C1320722
UMLS CUI-3
C0079744
Registrar's SWOG Roster ID Number
Description

RegistrarSouthwestOncologyGroupIdentifierNumber

Type de données

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

Type de données

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

Type de données

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
Patient Information
Description

Patient Information

Alias
UMLS CUI-1
C1955348
UMLS CUI-2
C0079744
Projected Start Date of Treatment
Description

Treatment Start Date

Type de données

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
Stratification Questions
Description

Stratification Questions

Based on centralized review, is the patient PET-positive after 3 cycles of R-CHOP?
Description

DiffuseLargeB-CellLymphomaPositronEmissionTomographyR-CHOPRegimenDiagnosisCode

Type de données

boolean

Alias
NCI Thesaurus ObjectClass
C8851
NCI Thesaurus Property
C17007
NCI Thesaurus Property-2
C15220
NCI Thesaurus Property-3
C9760
NCI Thesaurus ValueDomain
C25162
UMLS CUI [1,1]
C0079744
UMLS CUI [1,2]
C0032743
UMLS CUI [1,3]
C0011900
Patient Eligibility
Description

Patient Eligibility

Alias
UMLS CUI-1
C1516637
UMLS CUI-2
C0013893
UMLS CUI-3
C0079744
Has the SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
Description

SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

Type de données

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 [1,1]
C0013893
UMLS CUI [1,2]
C1519429
Auxiliary Questions
Description

Auxiliary Questions

Alias
UMLS CUI-1
C0587500
UMLS CUI-2
C1955348
UMLS CUI-3
C0079744
RT Start Date
Description

Radiation Therapy Start Date

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15313
NCI Thesaurus Property
C25431
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C1522449
UMLS CUI [1,2]
C0808070
RT Facility Name
Description

InstitutionRadiationTherapyAdministrationName

Type de données

text

Alias
NCI Thesaurus ObjectClass
C41206
NCI Thesaurus Property
C15313
NCI Thesaurus Property-2
C25409
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C1522449
RT Physician
Description

RadiationOncologyPhysicianName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C17833
UMLS CUI [1,1]
C0260194
UMLS CUI [1,2]
C1547383
UMLS CUI [1,3]
C0600091
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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 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Protocol Information
C1507394 (UMLS CUI-1)
C0079744 (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 Patient Id
Trial subject ID SWOG
Item
SWOG Patient ID
float
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
Item Group
SWOG Institutions
C1519429 (UMLS CUI-1)
C1320722 (UMLS CUI-2)
C0079744 (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)
C1519429 (UMLS CUI [1,1])
C1272753 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Item Group
Patient Information
C1955348 (UMLS CUI-1)
C0079744 (UMLS CUI-2)
Treatment Start Date
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
Stratification Questions
Based on centralized review, is the patient PET-positive after 3 cycles of R-CHOP
Item
Based on centralized review, is the patient PET-positive after 3 cycles of R-CHOP?
boolean
C8851 (NCI Thesaurus ObjectClass)
C17007 (NCI Thesaurus Property)
C15220 (NCI Thesaurus Property-2)
C9760 (NCI Thesaurus Property-3)
C25162 (NCI Thesaurus ValueDomain)
C0079744 (UMLS CUI [1,1])
C0032743 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item Group
Patient Eligibility
C1516637 (UMLS CUI-1)
C0013893 (UMLS CUI-2)
C0079744 (UMLS CUI-3)
SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0
Item
Has the SWOG 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 [1,1])
C1519429 (UMLS CUI [1,2])
Item Group
Auxiliary Questions
C0587500 (UMLS CUI-1)
C1955348 (UMLS CUI-2)
C0079744 (UMLS CUI-3)
Radiation Therapy Start Date
Item
RT Start Date
date
C15313 (NCI Thesaurus ObjectClass)
C25431 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1522449 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
RT Facility Name
Item
RT Facility Name
text
C41206 (NCI Thesaurus ObjectClass)
C15313 (NCI Thesaurus Property)
C25409 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C1301943 (UMLS CUI [1,1])
C1522449 (UMLS CUI [1,2])
RT Physician
Item
RT Physician
text
C25191 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C17833 (NCI Thesaurus ObjectClass-2)
C0260194 (UMLS CUI [1,1])
C1547383 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
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