ID

41983

Description

GOG Registration Form - 2058698v3.0 Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix https://clinicaltrials.gov/ct2/show/NCT00064077

Link

https://clinicaltrials.gov/ct2/show/NCT00064077

Keywords

Versions (3)
  1. 8/27/12 8/27/12 -
  2. 6/26/17 6/26/17 - Martin Dugas
  3. 3/15/21 3/15/21 - Dr. rer. medic Philipp Neuhaus
Uploaded on

March 15, 2021

DOI

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License

Creative Commons BY 4.0
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Cervical Cancer Cisplatin NCT00064077 GOG

English

FORM R

1 forms  
  1. StudyEvent: GOG Registration Form
    1. FORM R
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Form completion date, original
Description

Form Completion Date

Data type

date

Alias
UMLS CUI [1]
C1549507
Date form amended
Description

Form Completion Date, amended

Data type

date

Alias
UMLS CUI [1,1]
C0680532
UMLS CUI [1,2]
C0011008
Person amending form, last name
Description

Responsible Person Reporting Change LastName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25364
UMLS CUI [1,1]
C0680532
UMLS CUI [1,2]
C1547383
Patient Name, Last
Description

Last Name

Data type

text

Alias
UMLS CUI [1]
C1301584
Patient Name, First
Description

First Name

Data type

text

Alias
UMLS CUI [1]
C1443235
Patient Study ID
Description

Patient Study ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Person Completing Form, Last Name
Description

Person Completing Form, LastName

Data type

text

Alias
UMLS CUI [1,1]
C1550483
UMLS CUI [1,2]
C1301584
Participating Group Code
Description

Participating Group Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI [1]
C2986314
Participating Group Protocol No.
Description

Participating Group Protocol Number

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C2347449
Participating Patient Study ID
Description

Patient Participating Identifier Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
COMMENTS
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Tracking Information
Description

Tracking Information

Alias
UMLS CUI-1
C3889413
Institution name (affiliate)
Description

Institution Name

Data type

text

Alias
UMLS CUI [1]
C1301943
Treating physician
Description

Treating Physician

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C25705
UMLS CUI [1]
C1710470
Patient medical record number
Description

Patient Medical Record Number

Data type

text

Alias
UMLS CUI [1]
C1301894
Patient Birth Date
Description

Birth Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25275
UMLS CUI [1]
C0421451
Patient social security number
Description

Social Security Number

Data type

text

Alias
UMLS CUI [1]
C1301821
Patient´s zip code (USA)
Description

Patient Postal Code

Data type

text

Alias
UMLS CUI [1]
C0421454
Country of residence (if not USA)
Description

Patient Country

Data type

text

Alias
UMLS CUI [1,1]
C1562954
UMLS CUI [1,2]
C0421449
Demographic Information
Description

Demographic Information

Alias
UMLS CUI-1
C1704791
Patient race (mark all that apply)
Description

Patient Race

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
UMLS CUI [1]
C0034510
Patient ethnicity (check one)
Description

Patient Ethnicity

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
UMLS CUI [1]
C0015031
Method of payment
Description

Payment Method

Data type

integer

Alias
UMLS CUI [1]
C0680264
Other (Payment Method), specify
Description

Patient Payment Specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25371
UMLS CUI [1]
C0680264
Patient height
Description

Patient height

Data type

float

Measurement units
  • cm
Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25347
UMLS CUI [1]
C0489786
cm
Weight
Description

Patient Weight

Data type

float

Measurement units
  • Kg
Alias
UMLS CUI [1]
C0005910
Kg
Performance status (Zubrod)
Description

Performance Status

Data type

integer

Alias
UMLS CUI [1]
C1520224
Has the patient had any prior cancer diagnosed?
Description

Prior Cancer

Data type

boolean

Alias
UMLS CUI [1]
C2735088
Prior cancer type
Description

Prior Cancer Type

Data type

text

Alias
UMLS CUI [1]
C2735088
Prior cancer diagnosis date
Description

Prior Cancer Diagnosis Date

Data type

date

Alias
UMLS CUI [1,1]
C2735088
UMLS CUI [1,2]
C0011008
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Similar models

FORM R

1 forms
  1. StudyEvent: GOG Registration Form
    1. FORM R
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Form Completion Date
Item
Form completion date, original
date
C1549507 (UMLS CUI [1])
Form Completion Date, amended
Item
Date form amended
date
C0680532 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Responsible Person Reporting Change LastName
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C0680532 (UMLS CUI [1,1])
C1547383 (UMLS CUI [1,2])
Last Name
Item
Patient Name, Last
text
C1301584 (UMLS CUI [1])
First Name
Item
Patient Name, First
text
C1443235 (UMLS CUI [1])
Patient Study ID
Item
Patient Study ID
text
C2348585 (UMLS CUI [1])
Person Completing Form, LastName
Item
Person Completing Form, Last Name
text
C1550483 (UMLS CUI [1,1])
C1301584 (UMLS CUI [1,2])
Participating Group Code
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C2986314 (UMLS CUI [1])
Participating Group Protocol Number
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Patient Participating Identifier Number
Item
Participating Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Comments
Item
COMMENTS
text
C0947611 (UMLS CUI [1])
Item Group
Tracking Information
C3889413 (UMLS CUI-1)
Institution Name
Item
Institution name (affiliate)
text
C1301943 (UMLS CUI [1])
Treating Physician
Item
Treating physician
text
C25364 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI [1])
Patient Medical Record Number
Item
Patient medical record number
text
C1301894 (UMLS CUI [1])
Birth Date
Item
Patient Birth Date
date
C16960 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0421451 (UMLS CUI [1])
Social Security Number
Item
Patient social security number
text
C1301821 (UMLS CUI [1])
Patient Postal Code
Item
Patient´s zip code (USA)
text
C0421454 (UMLS CUI [1])
Patient Country
Item
Country of residence (if not USA)
text
C1562954 (UMLS CUI [1,1])
C0421449 (UMLS CUI [1,2])
Item Group
Demographic Information
C1704791 (UMLS CUI-1)
Item
Patient race (mark all that apply)
integer
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS CUI [1])
CL.1
Code List
Patient race (mark all that apply)
CL Item
American Indian or Alaska Native (1)
C0683984 (UMLS CUI-1)
CL Item
Asian (2)
C0078988 (UMLS CUI-1)
CL Item
Black or African (3)
C0085756 (UMLS CUI-1)
CL Item
Native Hawaiian or other Pacific Islander (4)
C0337920 (UMLS CUI-1)
CL Item
Unknown (5)
C0439673 (UMLS CUI-1)
CL Item
White (6)
C0007457 (UMLS CUI-1)
Item
Patient ethnicity (check one)
integer
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0015031 (UMLS CUI [1])
CL.2
Code List
Patient ethnicity (check one)
CL Item
Hispanic or Latino (1)
C0019576 (UMLS CUI-1)
CL Item
Non-Hispanic (2)
C1518424 (UMLS CUI-1)
CL Item
Unknown (3)
C0439673 (UMLS CUI-1)
Item
Method of payment
integer
C0680264 (UMLS CUI [1])
CL.3
Code List
Method of payment
CL Item
Private Insurance (1)
C3845555 (UMLS CUI-1)
CL Item
Medicare (2)
C0018717 (UMLS CUI-1)
CL Item
Medicare And Private Insurance (3)
C0018717 (UMLS CUI-1)
C3845555 (UMLS CUI-2)
CL Item
Medicaid (4)
C0596896 (UMLS CUI-1)
CL Item
Medicaid And Medicare (5)
C0596896 (UMLS CUI-1)
C0018717 (UMLS CUI-2)
CL Item
Military or Veterans Sponsored NOS (6)
C3245458 (UMLS CUI-1)
C0042610 (UMLS CUI-2)
CL Item
Military Sponsored (including Champus & Tricare) (7)
C3245458 (UMLS CUI-1)
CL Item
Veterans Sponsored (8)
C0042610 (UMLS CUI-1)
CL Item
Self Pay (no Insurance) (9)
C3530213 (UMLS CUI-1)
CL Item
No Means Of Payment (no Insurance) (10)
C0021682 (UMLS CUI-1)
C1518422 (UMLS CUI-2)
CL Item
Unknown (11)
C0439673 (UMLS CUI-1)
CL Item
Other, specify (12)
C3845569 (UMLS CUI-1)
Patient Payment Specify
Item
Other (Payment Method), specify
text
C25685 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS CUI [1])
Patient height
Item
Patient height
float
C16960 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS CUI [1])
Patient Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Item
Performance status (Zubrod)
integer
C1520224 (UMLS CUI [1])
CL.4
Code List
Performance status (Zubrod)
CL Item
Fully active, able to carry on all pre-disease performance without restriction (Kamofsky 90-100) (0)
C3830346 (UMLS CUI-1)
CL Item
Restricted in physically strenuous activity, but ambulatory (K 70-80) (1)
C3830345 (UMLS CUI-1)
CL Item
Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50-60) (2)
C3830344 (UMLS CUI-1)
CL Item
Capable of only limited selfcare, confined to bed or chair for more than 50% of waking hours (K 30-40) (3)
C3830343 (UMLS CUI-1)
CL Item
Completely disabled (K 10-20) (4)
C3830342 (UMLS CUI-1)
Prior Cancer
Item
Has the patient had any prior cancer diagnosed?
boolean
C2735088 (UMLS CUI [1])
Prior Cancer Type
Item
Prior cancer type
text
C2735088 (UMLS CUI [1])
Prior Cancer Diagnosis Date
Item
Prior cancer diagnosis date
date
C2735088 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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