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2613

Description

Registration Worksheet (RW) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B123165F-AFDA-4C3D-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B123165F-AFDA-4C3D-E034-0003BA12F5E7

Keywords

Versions (1)
  1. 9/19/12 9/19/12 -
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    Melanoma (Skin) null Registration - Registration Worksheet (RW) - 2073173v3.0

    English

    Instructions: Please fill-in the appropriate circle for each Inclusion and Exclusion Criterion. Each criterion must be marked and all protocol criteria have to be met prior to registering the patient.

    1 forms  
    Patient Information
    Description

    Patient Information

    Birthdate: (Year Month Day)
    Description

    PatientBirthDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Sex:
    Description

    PatientGender

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17357
    UMLS 2011AA Property
    C0079399
    Race: (Mark all that apply)
    Description

    PatientRace

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    Date of History and Physical: (within 60 days prior to registration)
    Description

    AssessmentDate

    Data type

    date

    Ethnicity: (Mark all that apply)
    Description

    PatientEthnicity

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    Completed by:
    Description

    CompletedBy

    Data type

    text

    Weight: (kg)
    Description

    PatientWeight

    Data type

    double

    Date: (Year Month Day)
    Description

    FormCompletionDate,Original

    Data type

    date

    Height: (cm)
    Description

    PatientHeight

    Data type

    double

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25347
    UMLS 2011AA Property
    C0489786
    Social Security Number
    Description

    PatientSocialSecurityNumber

    Data type

    double

    Canada Postal Code
    Description

    PatientAddress,PostalCode

    Data type

    double

    Canada Postal Code
    Description

    PatientAddress,PostalCode

    Data type

    double

    Canada Postal Code
    Description

    PatientAddress,PostalCode

    Data type

    double

    Method of Payment (Mark all that apply:)
    Description

    PaymentMethod

    Data type

    text

    Other, (specify:)
    Description

    Other,

    Data type

    text

    Medical Record Number:
    Description

    PatientMedicalRecordNumber

    Data type

    text

    Country:
    Description

    PatientAddress,Country

    Data type

    text

    Study Informed Consent signed: (Year Month Day)
    Description

    StudyInformedConsentsigned:

    Data type

    text

    Inclusion Criteria:
    Description

    Inclusion Criteria:

    Patient must be >18 years of age at study registration.
    Description

    Patientmustbe>18yearsofageatstudyregistration.

    Data type

    text

    Patient must have primary invasive cutaneous melanoma of Breslow thickness 2 mm or greater, as determined by diagnostic biopsy (excisional, punch, or shave), within 90 days prior to registration. (Patient must have the following prestudy staging evaluations completed within 60 days prior to registration:)
    Description

    PatientmusthaveprimaryinvasivecutaneousmelanomaofBreslowthickness2mmorgreater,asdeterminedbydiagnosticbiopsy(excisional,punch,orshave),within90dayspriortoregistration.

    Data type

    text

    History and physical examination. Patient with signs, symptoms, or physical exam findings suspicious for metastatic disease must undergo further evaluation in order to maintain eligibility (see Recommendations for Evaluation of Potential Metastatic Diseas
    Description

    Historyandphysicalexamination.Patientwithsigns,symptoms,orphysicalexamfindingssuspiciousformetastaticdiseasemustundergofurtherevaluationinordertomaintaineligibility(seeRecommendationsforEvaluationofPotentialMetastaticDiseas

    Data type

    text

    P/A and lateral chest X-ray (CXR). Patient with abnormal CXR findings suspicious for metastatic disease must have a negative or equivocal chest CT or FDG-PET in order to maintain eligibility.
    Description

    P/AandlateralchestX-ray(CXR).PatientwithabnormalCXRfindingssuspiciousformetastaticdiseasemusthaveanegativeorequivocalchestCTorFDG-PETinordertomaintaineligibility.

    Data type

    text

    Serum lactate dehydrogenase (LDH) level. Patient with an elevated serum LDH, defined as a serum level greater than the upper limit of institutional normal, must have a negative or equivocal CT scan, MRI, ultrasound, or FDG-PET of the abdomen in order to m
    Description

    Serumlactatedehydrogenase(LDH)level.PatientwithanelevatedserumLDH,definedasaserumlevelgreaterthantheupperlimitofinstitutionalnormal,musthaveanegativeorequivocalCTscan,MRI,ultrasound,orFDG-PEToftheabdomeninordertom

    Data type

    text

    Patient or the patient?s legally acceptable representative must provide a signed and dated written informed consent prior to registration and any study-related procedures.
    Description

    Patientorthepatient?slegallyacceptablerepresentativemustprovideasignedanddatedwritteninformedconsentpriortoregistrationandanystudy-relatedprocedures.

    Data type

    text

    A survivor of prior cancer is eligible provided that ALL of the following criteria are met and documented: (The patient has undergone potentially curative therapy for all prior malignancies,)
    Description

    AsurvivorofpriorcanceriseligibleprovidedthatALLofthefollowingcriteriaaremetanddocumented:

    Data type

    text

    Exclusion Criteria:
    Description

    Exclusion Criteria:

    Patient has primary melanoma of mucosal or ocular origin, or located on a finger distal to the metacarpophalangeal joint, on a toe distal to the metatarsophalangeal joint, on the tip of the nose, on the eyelids or on the ear.
    Description

    Patienthasprimarymelanomaofmucosalorocularorigin,orlocatedonafingerdistaltothemetacarpophalangealjoint,onatoedistaltothemetatarsophalangealjoint,onthetipofthenose,ontheeyelidsorontheear.

    Data type

    text

    Patient has a history of a non-index primary melanoma of Breslow thickness 1 mm or greater, or any prior melanoma with a history of lymphatic, in-transit, or distant metastases.
    Description

    Patienthasahistoryofanon-indexprimarymelanomaofBreslowthickness1mmorgreater,oranypriormelanomawithahistoryoflymphatic,in-transit,ordistantmetastases.

    Data type

    text

    Patient has clinical evidence of regional lymph node metastases as evidenced by suspicious palpable regional lymphadenopathy or biopsy.
    Description

    Patienthasclinicalevidenceofregionallymphnodemetastasesasevidencedbysuspiciouspalpableregionallymphadenopathyorbiopsy.

    Data type

    text

    Patient has cutaneous in-transit metastases (more than 2 cm from the primary tumor) or gross clinical evidence of satellitosis (less than 2 cm from primary tumor).
    Description

    Patienthascutaneousin-transitmetastases(morethan2cmfromtheprimarytumor)orgrossclinicalevidenceofsatellitosis(lessthan2cmfromprimarytumor).

    Data type

    text

    Patient previously has had a wide excision of a melanoma at the site of the index lesion.
    Description

    Patientpreviouslyhashadawideexcisionofamelanomaatthesiteoftheindexlesion.

    Data type

    text

    Patient has had prior lymphatic surgery (i.e., lymph node dissections or open lymph node biopsies, including sentinel lymph node biopsies), in the area(s) of potential lymphatic drainage of the index melanoma.
    Description

    Patienthashadpriorlymphaticsurgery(i.e.,lymphnodedissectionsoropenlymphnodebiopsies,includingsentinellymphnodebiopsies),inthearea(s)ofpotentiallymphaticdrainageoftheindexmelanoma.

    Data type

    text

    Patient has clinical or radiographic evidence of probable metastatic disease.
    Description

    Patienthasclinicalorradiographicevidenceofprobablemetastaticdisease.

    Data type

    text

    Patient meets all eligibility criteria:
    Description

    ACOSOGPatientEligibilityInd-2

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass
    C19712
    UMLS 2011AA ObjectClass
    C1515944
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    Randomization
    Description

    Randomization

    Indicate arm assigned:
    Description

    Indicatearmassigned:

    Data type

    text

    Date of Diagnostic Biopsy: (within 90 days prior to registration)
    Description

    BiopsyDate

    Data type

    date

    Date of History and Physical: (within 60 days prior to registration)
    Description

    AssessmentDate

    Data type

    date

    Date of P/A and Lateral Chest X-ray: (within 60 days prior to registration)
    Description

    ChestX-RayAssessmentDate

    Data type

    date

    Date of LDH: (within 60 days prior to registration)
    Description

    Lab,Hematology,SampleCollectionDate

    Data type

    date

    Is LDH greater than upper limit of institutional norm:
    Description

    IsLDHgreaterthanupperlimitofinstitutionalnorm:

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Stratification
    Description

    Stratification

    Tumor thickness (on biopsy:)
    Description

    BreslowDepth

    Data type

    double

    Ulceration: (As documented in pathology report)
    Description

    UlcerationInd

    Data type

    text

    Location: (Axial:)
    Description

    Lesion,AnatomicSite

    Data type

    text

    Completed by:
    Description

    CompletedBy

    Data type

    text

    Date: (Year Month Day)
    Description

    FormCompletionDate,Original

    Data type

    date

    Ccrr Module For Registration Worksheet (rw)
    Description

    Ccrr Module For Registration Worksheet (rw)

    Patient ID (Pt. ID issued during registration or previously issued patient ID)
    Description

    Pt.ID

    Data type

    text

    Institution ID:
    Description

    InstitutionNo.

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Patient Name:
    Description

    PatientName

    Data type

    text

    Institution:
    Description

    InstitutionName

    Data type

    text

    Registration Date: (Year Month Day)
    Description

    RegistrationDate

    Data type

    text

    Has patient previously been registered to an ACOSOG study?
    Description

    PriorTherapyPatientAmericanCollegeofSurgeonsOncologyGroupStudyInd-2

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass
    C16124
    UMLS 2011AA ObjectClass
    C1514463
    NCI Thesaurus Property
    C19712
    UMLS 2011AA Property
    C1515944
    NCI Metathesaurus Property
    CL238692
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
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    Instructions: Please fill-in the appropriate circle for each Inclusion and Exclusion Criterion. Each criterion must be marked and all protocol criteria have to be met prior to registering the patient.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient Information
    PatientBirthDate
    Item
    Birthdate: (Year Month Day)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    Item
    Sex:
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17357 (NCI Thesaurus Property)
    C0079399 (UMLS 2011AA Property)
    CL.1
    Code List
    Sex:
    CL Item
    Male (Male)
    CL Item
    Female (Female)
    Item
    Race: (Mark all that apply)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    CL.2
    Code List
    Race: (Mark all that apply)
    CL Item
    White_cdus (White)
    CL Item
    Black_cdus (Black)
    CL Item
    Pacific_islander_cdus (Native Hawaiian or other Pacific Islander)
    CL Item
    Asian_cdus (Asian)
    CL Item
    Native_american_cdus (American Indian or Alaska native)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    AssessmentDate
    Item
    Date of History and Physical: (within 60 days prior to registration)
    date
    Item
    Ethnicity: (Mark all that apply)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    CL.3
    Code List
    Ethnicity: (Mark all that apply)
    CL Item
    Hispanic_or_latino (Hispanic or Latino)
    CL Item
    Non_hispanic (Non-Hispanic)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CompletedBy
    Item
    Completed by:
    text
    PatientWeight
    Item
    Weight: (kg)
    double
    FormCompletionDate,Original
    Item
    Date: (Year Month Day)
    date
    PatientHeight
    Item
    Height: (cm)
    double
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS 2011AA Property)
    PatientSocialSecurityNumber
    Item
    Social Security Number
    double
    PatientAddress,PostalCode
    Item
    Canada Postal Code
    double
    PatientAddress,PostalCode
    Item
    Canada Postal Code
    double
    PatientAddress,PostalCode
    Item
    Canada Postal Code
    double
    Item
    Method of Payment (Mark all that apply:)
    text
    CL.4
    Code List
    Method of Payment (Mark all that apply:)
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Military Or Veterans Sponsored Nos (Military or Veterans Sponsored NOS)
    CL Item
    Military Sponsored (including Champus & Tricare) (Military Sponsored)
    CL Item
    Veterans Sponsored (Veterans Sponsored)
    CL Item
    Self Pay (no Insurance) (Self pay)
    CL Item
    No Means Of Payment (no Insurance) (No means of payment)
    CL Item
    Other (Provincial Insurance Plan)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Other,
    Item
    Other, (specify:)
    text
    PatientMedicalRecordNumber
    Item
    Medical Record Number:
    text
    PatientAddress,Country
    Item
    Country:
    text
    Item
    Study Informed Consent signed: (Year Month Day)
    text
    CL.5
    Code List
    Study Informed Consent signed: (Year Month Day)
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    Item Group
    Inclusion Criteria:
    Item
    Patient must be >18 years of age at study registration.
    text
    CL.6
    Code List
    Patient must be >18 years of age at study registration.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient must have primary invasive cutaneous melanoma of Breslow thickness 2 mm or greater, as determined by diagnostic biopsy (excisional, punch, or shave), within 90 days prior to registration. (Patient must have the following prestudy staging evaluations completed within 60 days prior to registration:)
    text
    CL.7
    Code List
    Patient must have primary invasive cutaneous melanoma of Breslow thickness 2 mm or greater, as determined by diagnostic biopsy (excisional, punch, or shave), within 90 days prior to registration. (Patient must have the following prestudy staging evaluations completed within 60 days prior to registration:)
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    History and physical examination. Patient with signs, symptoms, or physical exam findings suspicious for metastatic disease must undergo further evaluation in order to maintain eligibility (see Recommendations for Evaluation of Potential Metastatic Diseas
    text
    CL.8
    Code List
    History and physical examination. Patient with signs, symptoms, or physical exam findings suspicious for metastatic disease must undergo further evaluation in order to maintain eligibility (see Recommendations for Evaluation of Potential Metastatic Diseas
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    P/A and lateral chest X-ray (CXR). Patient with abnormal CXR findings suspicious for metastatic disease must have a negative or equivocal chest CT or FDG-PET in order to maintain eligibility.
    text
    CL.9
    Code List
    P/A and lateral chest X-ray (CXR). Patient with abnormal CXR findings suspicious for metastatic disease must have a negative or equivocal chest CT or FDG-PET in order to maintain eligibility.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Serum lactate dehydrogenase (LDH) level. Patient with an elevated serum LDH, defined as a serum level greater than the upper limit of institutional normal, must have a negative or equivocal CT scan, MRI, ultrasound, or FDG-PET of the abdomen in order to m
    text
    CL.10
    Code List
    Serum lactate dehydrogenase (LDH) level. Patient with an elevated serum LDH, defined as a serum level greater than the upper limit of institutional normal, must have a negative or equivocal CT scan, MRI, ultrasound, or FDG-PET of the abdomen in order to m
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient or the patient?s legally acceptable representative must provide a signed and dated written informed consent prior to registration and any study-related procedures.
    text
    CL.11
    Code List
    Patient or the patient?s legally acceptable representative must provide a signed and dated written informed consent prior to registration and any study-related procedures.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    AsurvivorofpriorcanceriseligibleprovidedthatALLofthefollowingcriteriaaremetanddocumented:
    Item
    A survivor of prior cancer is eligible provided that ALL of the following criteria are met and documented: (The patient has undergone potentially curative therapy for all prior malignancies,)
    text
    Item Group
    Exclusion Criteria:
    Item
    Patient has primary melanoma of mucosal or ocular origin, or located on a finger distal to the metacarpophalangeal joint, on a toe distal to the metatarsophalangeal joint, on the tip of the nose, on the eyelids or on the ear.
    text
    CL.12
    Code List
    Patient has primary melanoma of mucosal or ocular origin, or located on a finger distal to the metacarpophalangeal joint, on a toe distal to the metatarsophalangeal joint, on the tip of the nose, on the eyelids or on the ear.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient has a history of a non-index primary melanoma of Breslow thickness 1 mm or greater, or any prior melanoma with a history of lymphatic, in-transit, or distant metastases.
    text
    CL.13
    Code List
    Patient has a history of a non-index primary melanoma of Breslow thickness 1 mm or greater, or any prior melanoma with a history of lymphatic, in-transit, or distant metastases.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient has clinical evidence of regional lymph node metastases as evidenced by suspicious palpable regional lymphadenopathy or biopsy.
    text
    CL.14
    Code List
    Patient has clinical evidence of regional lymph node metastases as evidenced by suspicious palpable regional lymphadenopathy or biopsy.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient has cutaneous in-transit metastases (more than 2 cm from the primary tumor) or gross clinical evidence of satellitosis (less than 2 cm from primary tumor).
    text
    CL.15
    Code List
    Patient has cutaneous in-transit metastases (more than 2 cm from the primary tumor) or gross clinical evidence of satellitosis (less than 2 cm from primary tumor).
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient previously has had a wide excision of a melanoma at the site of the index lesion.
    text
    CL.16
    Code List
    Patient previously has had a wide excision of a melanoma at the site of the index lesion.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient has had prior lymphatic surgery (i.e., lymph node dissections or open lymph node biopsies, including sentinel lymph node biopsies), in the area(s) of potential lymphatic drainage of the index melanoma.
    text
    CL.17
    Code List
    Patient has had prior lymphatic surgery (i.e., lymph node dissections or open lymph node biopsies, including sentinel lymph node biopsies), in the area(s) of potential lymphatic drainage of the index melanoma.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient has clinical or radiographic evidence of probable metastatic disease.
    text
    CL.18
    Code List
    Patient has clinical or radiographic evidence of probable metastatic disease.
    CL Item
    Y (Y)
    CL Item
    N (N)
    C14562 (NCI Thesaurus)
    Item
    Patient meets all eligibility criteria:
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C19712 (NCI Thesaurus ObjectClass)
    C1515944 (UMLS 2011AA ObjectClass)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    CL.19
    Code List
    Patient meets all eligibility criteria:
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Randomization
    Item
    Indicate arm assigned:
    text
    CL.20
    Code List
    Indicate arm assigned:
    CL Item
    (arm 1) ((Arm 1))
    CL Item
    (arm 2) ((Arm 2))
    BiopsyDate
    Item
    Date of Diagnostic Biopsy: (within 90 days prior to registration)
    date
    AssessmentDate
    Item
    Date of History and Physical: (within 60 days prior to registration)
    date
    ChestX-RayAssessmentDate
    Item
    Date of P/A and Lateral Chest X-ray: (within 60 days prior to registration)
    date
    Lab,Hematology,SampleCollectionDate
    Item
    Date of LDH: (within 60 days prior to registration)
    date
    Item
    Is LDH greater than upper limit of institutional norm:
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.21
    Code List
    Is LDH greater than upper limit of institutional norm:
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Stratification
    BreslowDepth
    Item
    Tumor thickness (on biopsy:)
    double
    Item
    Ulceration: (As documented in pathology report)
    text
    CL.22
    Code List
    Ulceration: (As documented in pathology report)
    CL Item
    Yes (present)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (absent)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Location: (Axial:)
    text
    CL.23
    Code List
    Location: (Axial:)
    CL Item
    head/neck (head/neck)
    CL Item
    trunk, shoulders, hips, buttocks, genitalia (trunk, shoulders, hips, buttocks, genitalia)
    CL Item
    distal to elbows or knees (distal to elbows or knees)
    CL Item
    proximal (proximal)
    CompletedBy
    Item
    Completed by:
    text
    FormCompletionDate,Original
    Item
    Date: (Year Month Day)
    date
    Item Group
    Ccrr Module For Registration Worksheet (rw)
    Pt.ID
    Item
    Patient ID (Pt. ID issued during registration or previously issued patient ID)
    text
    InstitutionNo.
    Item
    Institution ID:
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    PatientName
    Item
    Patient Name:
    text
    InstitutionName
    Item
    Institution:
    text
    RegistrationDate
    Item
    Registration Date: (Year Month Day)
    text
    Item
    Has patient previously been registered to an ACOSOG study?
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C16124 (NCI Thesaurus ObjectClass)
    C1514463 (UMLS 2011AA ObjectClass)
    C19712 (NCI Thesaurus Property)
    C1515944 (UMLS 2011AA Property)
    CL238692 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.24
    Code List
    Has patient previously been registered to an ACOSOG study?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
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