ID

3247

Descrizione

S0205 Registration Form S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11C9703-C8D4-1BF2-E034-080020C9C0E0

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11C9703-C8D4-1BF2-E034-080020C9C0E0

Keywords

versioni (4)
  1. 19/09/12 19/09/12 -
  2. 02/06/15 02/06/15 -
  3. 03/06/15 03/06/15 -
  4. 20/09/21 20/09/21 -
Caricato su

19 settembre 2012

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00075686 Registration - S0205 Registration Form - 2035914v3.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
Unnamed1
Descrizione

Unnamed1

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Assigned Treatment Arm
Descrizione

TreatmentArmNumber

Tipo di dati

text

Activation Date
Descrizione

ProtocolActivationDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25405
UMLS 2011AA Property
C1515882
Last Amended Date
Descrizione

FormCompletionDate,Amended

Tipo di dati

date

Unnamed2
Descrizione

Unnamed2

A Phase Iii Randomized Open-label Study Comparing Gemcitabine Plus Imc-225 (cetuximab) Versus Gemcitabine As First-line Therapy Of Patients With Advanced Pancreas Cancer
Descrizione

A Phase Iii Randomized Open-label Study Comparing Gemcitabine Plus Imc-225 (cetuximab) Versus Gemcitabine As First-line Therapy Of Patients With Advanced Pancreas Cancer

Patient's Name
Descrizione

Patient'sName

Tipo di dati

text

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

Unnamed 3
Descrizione

Unnamed 3

Caller's SWOG Roster ID
Descrizione

RegistrarSouthwestOncologyGroupIdentifierNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25699
UMLS 2011AA Property
C1519429
NCI Thesaurus ObjectClass
C25357
UMLS 2011AA ObjectClass
C0557514
SWOG Treating Institution Number
Descrizione

NCIInstitutionNumber

Tipo di dati

text

Date Informed Consent Signed
Descrizione

InformedConsentDateSigned

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
SWOG Investigator Number
Descrizione

SWOGInvestigatorNumber

Tipo di dati

text

IRB Approval Date
Descrizione

IRBApprovalDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Descrizione

ProjectedTreatmentBeginDate

Tipo di dati

date

Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer
Descrizione

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Tipo di dati

text

Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
Descrizione

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Tipo di dati

text

Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
Descrizione

PatientInitialConsent,Specimen,ContactInd

Tipo di dati

text

Unnamed 4
Descrizione

Unnamed 4

Patient's Date of Birth
Descrizione

PatientBirthDate

Tipo di dati

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient's Sex
Descrizione

PatientGender

Tipo di dati

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
Method of Payment
Descrizione

PaymentMethod

Tipo di dati

text

Patient's Ethnicity
Descrizione

Patient'sEthnicity

Tipo di dati

text

Patient's Race (select all that apply)
Descrizione

PatientRace

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Other, specify (If a U.S. resident)
Descrizione

Other,specify

Tipo di dati

text

Patient's ZIP Code
Descrizione

PatientAddress,PostalCode

Tipo di dati

double

Country of Residence, if not USA (If a resident of Canada)
Descrizione

PatientAddress,Country

Tipo di dati

text

Social Insurance Number
Descrizione

PatientSocialSecurityNumber

Tipo di dati

double

Social Insurance Number
Descrizione

PatientSocialSecurityNumber

Tipo di dati

double

Postal Code
Descrizione

AddressPostalCode

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25407
UMLS 2011AA ObjectClass
C1442065
NCI Thesaurus Property
C25621
UMLS 2011AA Property
C1514254
Stratification Factors
Descrizione

StratificationFactors

Tipo di dati

text

Disease status
Descrizione

Diseasestatus

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Metathesaurus Property
C0449438
Zubrod Performance Status
Descrizione

PerformanceStatus

Tipo di dati

text

Unnamed5
Descrizione

Unnamed5

Comments
Descrizione

Comments

Tipo di dati

text

Ccrr Module For S0205 Registration Form
Descrizione

Ccrr Module For S0205 Registration Form

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Unnamed1
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
TreatmentArmNumber
Item
Assigned Treatment Arm
text
ProtocolActivationDate
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25405 (NCI Thesaurus Property)
C1515882 (UMLS 2011AA Property)
FormCompletionDate,Amended
Item
Last Amended Date
date
Item Group
Unnamed2
Item Group
A Phase Iii Randomized Open-label Study Comparing Gemcitabine Plus Imc-225 (cetuximab) Versus Gemcitabine As First-line Therapy Of Patients With Advanced Pancreas Cancer
Patient'sName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
Item Group
Unnamed 3
RegistrarSouthwestOncologyGroupIdentifierNumber
Item
Caller's SWOG Roster ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25699 (NCI Thesaurus Property)
C1519429 (UMLS 2011AA Property)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
NCIInstitutionNumber
Item
SWOG Treating Institution Number
text
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
IRBApprovalDate
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25425 (NCI Thesaurus Property)
C0205540 (UMLS 2011AA Property)
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
Item
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer
text
CL.1
Code List
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
text
CL.2
Code List
Patient's tissue may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
CL Item
Null (Yes)
CL Item
Null (No)
Item
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
text
CL.3
Code List
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
CL Item
Null (Yes)
CL Item
Null (No)
Item Group
Unnamed 4
PatientBirthDate
Item
Patient's Date of Birth
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
Patient's 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.4
Code List
Patient's Sex
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
Item
Method of Payment
text
CL.5
Code List
Method of Payment
CL Item
Private (Private)
CL Item
Medicare (Medicare)
CL Item
Medicare and Private (Medicare and Private)
CL Item
Medicaid (Medicaid)
CL Item
Medicaid and Medicare (Medicaid and Medicare)
CL Item
No insurance (self-pay) (No insurance (self-pay))
CL Item
No insurance (no means) (No insurance (no means))
CL Item
Other, speicfy at registration (Other, speicfy at registration)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Admin (Veterans Admin)
CL Item
Military (Military)
Item
Patient's Ethnicity
text
CL.6
Code List
Patient's Ethnicity
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (not Spanish) (No (not Spanish))
CL Item
Yes, Mexican (Yes, Mexican)
CL Item
Yes, Puerto Rican (Yes, Puerto Rican)
CL Item
Yes, Cuban (Yes, Cuban)
CL Item
Yes, Central American (Yes, Central American)
CL Item
Yes, South American (Yes, South American)
CL Item
Yes, Other (Yes, Other)
CL Item
Yes, Nos (Yes, NOS)
Item
Patient's Race (select all that apply)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.7
Code List
Patient's Race (select all that apply)
CL Item
White_cdus (White or Caucasian)
CL Item
Black_cdus (Black or African American)
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
Other, specify (Other, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Other,specify
Item
Other, specify (If a U.S. resident)
text
PatientAddress,PostalCode
Item
Patient's ZIP Code
double
PatientAddress,Country
Item
Country of Residence, if not USA (If a resident of Canada)
text
PatientSocialSecurityNumber
Item
Social Insurance Number
double
PatientSocialSecurityNumber
Item
Social Insurance Number
double
AddressPostalCode
Item
Postal Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
StratificationFactors
Item
Stratification Factors
text
Item
Disease status
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C0449438 (NCI Metathesaurus Property)
CL.8
Code List
Disease status
CL Item
Locally Advanced Unresectable (Locally advanced unresectable)
CL Item
Metastatic (Metastatic)
C14174 (NCI Thesaurus)
C0036525 (UMLS 2011AA)
Item
Zubrod Performance Status
text
CL.9
Code List
Zubrod Performance Status
CL Item
0 (0 to 1)
C0919414 (NCI Metathesaurus)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
Item Group
Unnamed5
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Registration Form
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