ID

3247

Beskrivning

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

Länk

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

Nyckelord

Versioner (4)
  1. 2012-09-19 2012-09-19 -
  2. 2015-06-02 2015-06-02 -
  3. 2015-06-03 2015-06-03 -
  4. 2021-09-20 2021-09-20 -
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19 september 2012

DOI

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Licens

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

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
Unnamed1
Beskrivning

Unnamed1

SWOG Study No.
Beskrivning

SWOGStudyNo.

Datatyp

text

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Assigned Treatment Arm
Beskrivning

TreatmentArmNumber

Datatyp

text

Activation Date
Beskrivning

ProtocolActivationDate

Datatyp

date

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

FormCompletionDate,Amended

Datatyp

date

Unnamed2
Beskrivning

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
Beskrivning

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
Beskrivning

Patient'sName

Datatyp

text

SWOG Patient ID
Beskrivning

SWOGPatientID

Datatyp

text

Unnamed 3
Beskrivning

Unnamed 3

Caller's SWOG Roster ID
Beskrivning

RegistrarSouthwestOncologyGroupIdentifierNumber

Datatyp

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
Beskrivning

NCIInstitutionNumber

Datatyp

text

Date Informed Consent Signed
Beskrivning

InformedConsentDateSigned

Datatyp

date

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

SWOGInvestigatorNumber

Datatyp

text

IRB Approval Date
Beskrivning

IRBApprovalDate

Datatyp

date

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

ProjectedTreatmentBeginDate

Datatyp

date

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

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datatyp

text

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

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datatyp

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.
Beskrivning

PatientInitialConsent,Specimen,ContactInd

Datatyp

text

Unnamed 4
Beskrivning

Unnamed 4

Patient's Date of Birth
Beskrivning

PatientBirthDate

Datatyp

date

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

PatientGender

Datatyp

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
Beskrivning

PaymentMethod

Datatyp

text

Patient's Ethnicity
Beskrivning

Patient'sEthnicity

Datatyp

text

Patient's Race (select all that apply)
Beskrivning

PatientRace

Datatyp

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)
Beskrivning

Other,specify

Datatyp

text

Patient's ZIP Code
Beskrivning

PatientAddress,PostalCode

Datatyp

double

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

PatientAddress,Country

Datatyp

text

Social Insurance Number
Beskrivning

PatientSocialSecurityNumber

Datatyp

double

Social Insurance Number
Beskrivning

PatientSocialSecurityNumber

Datatyp

double

Postal Code
Beskrivning

AddressPostalCode

Datatyp

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
Beskrivning

StratificationFactors

Datatyp

text

Disease status
Beskrivning

Diseasestatus

Datatyp

text

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

PerformanceStatus

Datatyp

text

Unnamed5
Beskrivning

Unnamed5

Comments
Beskrivning

Comments

Datatyp

text

Ccrr Module For S0205 Registration Form
Beskrivning

Ccrr Module For S0205 Registration Form

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: S0205 Registration Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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