ID

41983

Beschreibung

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

Stichworte

Versionen (3)
  1. 27.08.12 27.08.12 -
  2. 26.06.17 26.06.17 - Martin Dugas
  3. 15.03.21 15.03.21 - Dr. rer. medic Philipp Neuhaus
Hochgeladen am

15. März 2021

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY 4.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Cervical Cancer Cisplatin NCT00064077 GOG

Englisch

FORM R

1 Formulare  
  1. StudyEvent: GOG Registration Form
    1. FORM R
Header Module
Beschreibung

Header Module

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

Form Completion Date

Datentyp

date

Alias
UMLS CUI [1]
C1549507
Date form amended
Beschreibung

Form Completion Date, amended

Datentyp

date

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

Responsible Person Reporting Change LastName

Datentyp

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
Beschreibung

Last Name

Datentyp

text

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

First Name

Datentyp

text

Alias
UMLS CUI [1]
C1443235
Patient Study ID
Beschreibung

Patient Study ID

Datentyp

text

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

Person Completing Form, LastName

Datentyp

text

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

Participating Group Code

Datentyp

text

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

Participating Group Protocol Number

Datentyp

text

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

Patient Participating Identifier Number

Datentyp

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
Beschreibung

Comments

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Tracking Information
Beschreibung

Tracking Information

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

Institution Name

Datentyp

text

Alias
UMLS CUI [1]
C1301943
Treating physician
Beschreibung

Treating Physician

Datentyp

text

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

Patient Medical Record Number

Datentyp

text

Alias
UMLS CUI [1]
C1301894
Patient Birth Date
Beschreibung

Birth Date

Datentyp

date

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

Social Security Number

Datentyp

text

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

Patient Postal Code

Datentyp

text

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

Patient Country

Datentyp

text

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

Demographic Information

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

Patient Race

Datentyp

integer

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

Patient Ethnicity

Datentyp

integer

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

Payment Method

Datentyp

integer

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

Patient Payment Specify

Datentyp

text

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

Patient height

Datentyp

float

Maßeinheiten
  • cm
Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25347
UMLS CUI [1]
C0489786
cm
Weight
Beschreibung

Patient Weight

Datentyp

float

Maßeinheiten
  • Kg
Alias
UMLS CUI [1]
C0005910
Kg
Performance status (Zubrod)
Beschreibung

Performance Status

Datentyp

integer

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

Prior Cancer

Datentyp

boolean

Alias
UMLS CUI [1]
C2735088
Prior cancer type
Beschreibung

Prior Cancer Type

Datentyp

text

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

Prior Cancer Diagnosis Date

Datentyp

date

Alias
UMLS CUI [1,1]
C2735088
UMLS CUI [1,2]
C0011008
Zum Seitenanfang zurückkehren

Ähnliche Modelle

FORM R

1 Formulare
  1. StudyEvent: GOG Registration Form
    1. FORM R
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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])
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video