ID

25262

Description

Southwest Oncology Group S0816 REGISTRATION WORKSHEET - Step 2 Fludeoxyglucose F 18-PET/CT Imaging and Combination Chemotherapy With or Without Additional Chemotherapy and G-CSF in Treating Patients With Stage III or Stage IV Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D88149E-29DD-7E58-E040-BB89AD432F8E

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D88149E-29DD-7E58-E040-BB89AD432F8E

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/29/17 8/29/17 -
Uploaded on

August 29, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group S0816 REGISTRATION WORKSHEET - Step 2

English

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 forms  
Protocol Information
Description

Protocol Information

Alias
UMLS CUI-1
C1507394
UMLS CUI-2
C0019829
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
For SWOG Institutions
Description

For SWOG Institutions

Alias
UMLS CUI-1
C1519429
UMLS CUI-2
C1320722
UMLS CUI-3
C0019829
Registrar's SWOG Roster ID Number
Description

RegistrarSouthwestOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C25699
UMLS 2011AA Property-2
C1519429
NCI Thesaurus ObjectClass
C25357
UMLS 2011AA ObjectClass
C0557514
SWOG Investigator Number
Description

SouthwestOncologyGroupInvestigatorIdentifierNumber

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25699
NCI Thesaurus ObjectClass-2
C17089
UMLS CUI [1,1]
C0237753
UMLS CUI [1,2]
C0600091
UMLS CUI [1,3]
C1519429
UMLS CUI [1,4]
C0035173
SWOG Treating Institution Number
Description

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Data type

integer

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]
C1522326
UMLS CUI [1,3]
C1272753
UMLS CUI [1,4]
C0600091
UMLS CUI [1,5]
C0237753
Patient Information
Description

Patient Information

Alias
UMLS CUI-1
C1955348
UMLS CUI-2
C0019829
Projected Start Date of Treatment
Description

Treatment Start Date

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
UMLS CUI [2]
C0019829
Stratification Questions
Description

Stratification Questions

Alias
UMLS CUI-1
C1514983
UMLS CUI-2
C0019829
Based on centralized review, is the patient PET-positive after 2 cycles of ABVD?
Description

CentralPathologyReviewPostABVDRegimenHodgkinLymphomaPositronEmissionTomographyConfirmedCode

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C71684
NCI Thesaurus Property
C25458
NCI Thesaurus Property-2
C17007
NCI Thesaurus Property-3
C9357
NCI Thesaurus Property-4
C38008
NCI Thesaurus Property-5
C9509
NCI Thesaurus ValueDomain
C25162
UMLS CUI [1,1]
C0032743
UMLS CUI [1,2]
C0019829
UMLS CUI [2]
C0050380
UMLS CUI [3]
C2347585
Patient Eligibility
Description

Patient Eligibility

Alias
UMLS CUI-1
C1516637
UMLS CUI-2
C0013893
UMLS CUI-3
C0019829
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 [1,1]
C0013893
UMLS CUI [1,2]
C1514821
UMLS CUI [1,3]
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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Protocol Information
C1507394 (UMLS CUI-1)
C0019829 (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
For SWOG Institutions
C1519429 (UMLS CUI-1)
C1320722 (UMLS CUI-2)
C0019829 (UMLS CUI-3)
Registrar's SWOG Roster ID Number
Item
Registrar's SWOG Roster ID Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus Property-2)
C1519429 (UMLS 2011AA Property-2)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
SWOG Investigator Number
Item
SWOG Investigator Number
integer
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus ObjectClass)
C17089 (NCI Thesaurus ObjectClass-2)
C0237753 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C1519429 (UMLS CUI [1,3])
C0035173 (UMLS CUI [1,4])
SWOG Treating Institution Number
Item
SWOG Treating Institution Number
integer
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])
C1522326 (UMLS CUI [1,2])
C1272753 (UMLS CUI [1,3])
C0600091 (UMLS CUI [1,4])
C0237753 (UMLS CUI [1,5])
Item Group
Patient Information
C1955348 (UMLS CUI-1)
C0019829 (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])
C0019829 (UMLS CUI [2])
Item Group
Stratification Questions
C1514983 (UMLS CUI-1)
C0019829 (UMLS CUI-2)
Based on centralized review, is the patient PET-positive after 2 cycles of ABVD
Item
Based on centralized review, is the patient PET-positive after 2 cycles of ABVD?
boolean
C71684 (NCI Thesaurus ObjectClass)
C25458 (NCI Thesaurus Property)
C17007 (NCI Thesaurus Property-2)
C9357 (NCI Thesaurus Property-3)
C38008 (NCI Thesaurus Property-4)
C9509 (NCI Thesaurus Property-5)
C25162 (NCI Thesaurus ValueDomain)
C0032743 (UMLS CUI [1,1])
C0019829 (UMLS CUI [1,2])
C0050380 (UMLS CUI [2])
C2347585 (UMLS CUI [3])
Item Group
Patient Eligibility
C1516637 (UMLS CUI-1)
C0013893 (UMLS CUI-2)
C0019829 (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 [1,1])
C1514821 (UMLS CUI [1,2])
C1519429 (UMLS CUI [1,3])
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