ID

2613

Descripción

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

Palabras clave

Versiones (1)
  1. 19/9/12 19/9/12 -
Subido en

19 de septiembre de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

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

Inglés

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 formularios  
Patient Information
Descripción

Patient Information

Birthdate: (Year Month Day)
Descripción

PatientBirthDate

Tipo de datos

date

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

PatientGender

Tipo de datos

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)
Descripción

PatientRace

Tipo de datos

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)
Descripción

AssessmentDate

Tipo de datos

date

Ethnicity: (Mark all that apply)
Descripción

PatientEthnicity

Tipo de datos

text

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

CompletedBy

Tipo de datos

text

Weight: (kg)
Descripción

PatientWeight

Tipo de datos

double

Date: (Year Month Day)
Descripción

FormCompletionDate,Original

Tipo de datos

date

Height: (cm)
Descripción

PatientHeight

Tipo de datos

double

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

PatientSocialSecurityNumber

Tipo de datos

double

Canada Postal Code
Descripción

PatientAddress,PostalCode

Tipo de datos

double

Canada Postal Code
Descripción

PatientAddress,PostalCode

Tipo de datos

double

Canada Postal Code
Descripción

PatientAddress,PostalCode

Tipo de datos

double

Method of Payment (Mark all that apply:)
Descripción

PaymentMethod

Tipo de datos

text

Other, (specify:)
Descripción

Other,

Tipo de datos

text

Medical Record Number:
Descripción

PatientMedicalRecordNumber

Tipo de datos

text

Country:
Descripción

PatientAddress,Country

Tipo de datos

text

Study Informed Consent signed: (Year Month Day)
Descripción

StudyInformedConsentsigned:

Tipo de datos

text

Inclusion Criteria:
Descripción

Inclusion Criteria:

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

Patientmustbe>18yearsofageatstudyregistration.

Tipo de datos

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:)
Descripción

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

Tipo de datos

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
Descripción

Historyandphysicalexamination.Patientwithsigns,symptoms,orphysicalexamfindingssuspiciousformetastaticdiseasemustundergofurtherevaluationinordertomaintaineligibility(seeRecommendationsforEvaluationofPotentialMetastaticDiseas

Tipo de datos

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.
Descripción

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

Tipo de datos

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
Descripción

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

Tipo de datos

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.
Descripción

Patientorthepatient?slegallyacceptablerepresentativemustprovideasignedanddatedwritteninformedconsentpriortoregistrationandanystudy-relatedprocedures.

Tipo de datos

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,)
Descripción

AsurvivorofpriorcanceriseligibleprovidedthatALLofthefollowingcriteriaaremetanddocumented:

Tipo de datos

text

Exclusion Criteria:
Descripción

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.
Descripción

Patienthasprimarymelanomaofmucosalorocularorigin,orlocatedonafingerdistaltothemetacarpophalangealjoint,onatoedistaltothemetatarsophalangealjoint,onthetipofthenose,ontheeyelidsorontheear.

Tipo de datos

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.
Descripción

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

Tipo de datos

text

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

Patienthasclinicalevidenceofregionallymphnodemetastasesasevidencedbysuspiciouspalpableregionallymphadenopathyorbiopsy.

Tipo de datos

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).
Descripción

Patienthascutaneousin-transitmetastases(morethan2cmfromtheprimarytumor)orgrossclinicalevidenceofsatellitosis(lessthan2cmfromprimarytumor).

Tipo de datos

text

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

Patientpreviouslyhashadawideexcisionofamelanomaatthesiteoftheindexlesion.

Tipo de datos

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.
Descripción

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

Tipo de datos

text

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

Patienthasclinicalorradiographicevidenceofprobablemetastaticdisease.

Tipo de datos

text

Patient meets all eligibility criteria:
Descripción

ACOSOGPatientEligibilityInd-2

Tipo de datos

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
Descripción

Randomization

Indicate arm assigned:
Descripción

Indicatearmassigned:

Tipo de datos

text

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

BiopsyDate

Tipo de datos

date

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

AssessmentDate

Tipo de datos

date

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

ChestX-RayAssessmentDate

Tipo de datos

date

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

Lab,Hematology,SampleCollectionDate

Tipo de datos

date

Is LDH greater than upper limit of institutional norm:
Descripción

IsLDHgreaterthanupperlimitofinstitutionalnorm:

Tipo de datos

text

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

Stratification

Tumor thickness (on biopsy:)
Descripción

BreslowDepth

Tipo de datos

double

Ulceration: (As documented in pathology report)
Descripción

UlcerationInd

Tipo de datos

text

Location: (Axial:)
Descripción

Lesion,AnatomicSite

Tipo de datos

text

Completed by:
Descripción

CompletedBy

Tipo de datos

text

Date: (Year Month Day)
Descripción

FormCompletionDate,Original

Tipo de datos

date

Ccrr Module For Registration Worksheet (rw)
Descripción

Ccrr Module For Registration Worksheet (rw)

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

Pt.ID

Tipo de datos

text

Institution ID:
Descripción

InstitutionNo.

Tipo de datos

text

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

PatientName

Tipo de datos

text

Institution:
Descripción

InstitutionName

Tipo de datos

text

Registration Date: (Year Month Day)
Descripción

RegistrationDate

Tipo de datos

text

Has patient previously been registered to an ACOSOG study?
Descripción

PriorTherapyPatientAmericanCollegeofSurgeonsOncologyGroupStudyInd-2

Tipo de datos

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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Similar models

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 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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