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ID

42942

Descripción

E1A06 Registration Worksheet (Step 1) Melphalan, Prednisone, and Thalidomide or Lenalidomide in Treating Patients With Newly Diagnosed Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510B294D-430D-4275-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510B294D-430D-4275-E044-0003BA3F9857

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 17/9/21 17/9/21 -
Subido en

17 de septiembre de 2021

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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    Multiple Myeloma and Plasma Cell Neoplasm NCT00602641 Eligibility - E1A06 Registration Worksheet (Step 1) - 2762148v1.0

    Inglés

    No Instruction available.

    1 formularios  
    1. StudyEvent: E1A06 Registration Worksheet (Step 1)
      1. No Instruction available.
    Eligibility
    Descripción

    Eligibility

    First initial
    Descripción

    Patient Initials First

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C0205435
    NCI Thesaurus Property
    C25536
    NCI Thesaurus Property-2
    C25509
    Last initial
    Descripción

    Patient Initials Last

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1517741
    NCI Thesaurus Property
    C25536
    NCI Thesaurus Property-2
    C25551
    Has the eligibility checklist been completed
    Descripción

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C25171
    UMLS 2011AA ObjectClass
    C0013893
    NCI Thesaurus Property-2
    C49073
    UMLS 2011AA Property-2
    C1707357
    In the opinion of the investigator, is the patient eligible?
    Descripción

    Eligibility for trial

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1302261
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25171
    Has written informed consent been obtained
    Descripción

    Consent signed

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0742766
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25678
    NCI Thesaurus Property-2
    C25460
    Date Informed Consent Signed
    Descripción

    InformedConsentFormSignedDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Has HIPAA authorization been obtained
    Descripción

    HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C62504
    UMLS 2011AA ObjectClass
    C0600593
    NCI Thesaurus Property
    C41192
    UMLS 2011AA Property
    C1524004
    HIPAA Authorization Date
    Descripción

    PatientSignedDischargeMedicalRecordDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25679
    NCI Metathesaurus Property
    C0012621
    NCI Thesaurus Property-2
    C45258
    UMLS 2011AA Property
    C0025102
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Age at Registration
    Descripción

    PatientRegistrationAgeYearCount

    Tipo de datos

    float

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus ValueDomain
    C29848
    UMLS 2011AA ValueDomain
    C0439234
    NCI Thesaurus ValueDomain-2
    C25463
    UMLS 2011AA ValueDomain-2
    C0750480
    ISS stage
    Descripción

    MultipleMyelomaDiseaseStageDiagnosisStatus

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C3242
    UMLS 2011AA ObjectClass
    C0026764
    NCI Thesaurus ObjectClass-2
    C2991
    UMLS 2011AA ObjectClass-2
    C0012634
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus Property-2
    C16899
    UMLS 2011AA Property-2
    C1300072
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    Descripción

    PersonAncillaryStudyRegistrationText

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C16041
    UMLS 2011AA Property-2
    C1515980
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    Descripción

    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C15207
    NCI Thesaurus Property-3
    C25294
    UMLS 2011AA Property-2
    C0022885
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Descripción

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C9305
    UMLS 2011AA Property
    C0006826
    NCI Thesaurus Property-3
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    My specimens may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
    Descripción

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C12801
    UMLS 2011AA Property
    C0040300
    NCI Thesaurus Property-2
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Someone from this institution may contact me in the future to ask me to take part in more research.
    Descripción

    PatientAdditionalResearchConsentInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25406
    UMLS 2011AA Property
    C1524062
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient Demographics / Pre-treatment Characteristics
    Descripción

    Patient Demographics / Pre-treatment Characteristics

    Patient's Sex
    Descripción

    PatientSexCode

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C28421
    UMLS 2011AA Property
    C1522384
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ValueDomain-2
    C16960
    UMLS 2011AA ValueDomain-2
    C0030705
    NCI Thesaurus ValueDomain-3
    C28421
    UMLS 2011AA ValueDomain-3
    C1522384
    Birthdate (mm/yy)
    Descripción

    Birth Date

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0421451
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25155
    Patient's Race
    Descripción

    Racial Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0034510
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C17049
    ZIP Code
    Descripción

    AddressPostalCodeIdentifier

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25407
    UMLS 2011AA ObjectClass
    C1442065
    NCI Thesaurus Property
    C25621
    UMLS 2011AA Property
    C1514254
    NCI Thesaurus ValueDomain
    C25364
    UMLS 2011AA ValueDomain
    C0600091
    NCI Thesaurus ValueDomain-2
    C25407
    UMLS 2011AA ValueDomain-2
    C1442065
    NCI Thesaurus ValueDomain-3
    C25621
    UMLS 2011AA ValueDomain-3
    C1514254
    Patient Ethnicity
    Descripción

    Ethnic Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0015031
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C16564
    Patient Hospital No.
    Descripción

    Medical Record Number

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301894
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25261
    NCI Thesaurus Property-2
    C25198
    Patient Social Security Number
    Descripción

    Social Security Number

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301821
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25686
    Method of payment (check one)
    Descripción

    PatientInternationalPaymentType

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25371
    UMLS 2011AA Property
    C0680264
    NCI Thesaurus Property-2
    C25541
    UMLS 2011AA Property-2
    C1512888
    Country of residence
    Descripción

    PatientAddressCountryCode

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25407
    UMLS 2011AA Property
    C1442065
    Comments
    Descripción

    Research Comments

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct
    Descripción

    I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct

    Signature of treating physician
    Descripción

    TreatingPhysicianSignatureText

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C51883
    UMLS 2011AA ObjectClass
    C1710470
    Date
    Descripción

    TreatingPhysicianSignatureDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C51883
    UMLS 2011AA ObjectClass
    C1710470
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    1 formularios
    1. StudyEvent: E1A06 Registration Worksheet (Step 1)
      1. No Instruction available.
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de datos
    Alias
    Item Group
    Eligibility
    Patient Initials First
    Item
    First initial
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C0205435 (UMLS CUI-2)
    C25536 (NCI Thesaurus Property)
    C25509 (NCI Thesaurus Property-2)
    Patient Initials Last
    Item
    Last initial
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1517741 (UMLS CUI-2)
    C25536 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    EligibilityDeterminationChecklistCompleteEligibilityInd-2
    Item
    Has the eligibility checklist been completed
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus ObjectClass)
    C0013893 (UMLS 2011AA ObjectClass)
    C49073 (NCI Thesaurus Property-2)
    C1707357 (UMLS 2011AA Property-2)
    Eligibility for trial
    Item
    In the opinion of the investigator, is the patient eligible?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1302261 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25171 (NCI Thesaurus Property)
    Consent signed
    Item
    Has written informed consent been obtained
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C0742766 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25678 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    Item
    Has HIPAA authorization been obtained
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C62504 (NCI Thesaurus ObjectClass)
    C0600593 (UMLS 2011AA ObjectClass)
    C41192 (NCI Thesaurus Property)
    C1524004 (UMLS 2011AA Property)
    CL.4
    Code List
    Has HIPAA authorization been obtained
    CL Item
    No: C49487 (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes: C49488 (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Exempt - Non-usa Participant (Exempt - non-USA participant)
    PatientSignedDischargeMedicalRecordDate
    Item
    HIPAA Authorization Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C0012621 (NCI Metathesaurus Property)
    C45258 (NCI Thesaurus Property-2)
    C0025102 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    PatientRegistrationAgeYearCount
    Item
    Age at Registration
    float
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    C29848 (NCI Thesaurus ValueDomain)
    C0439234 (UMLS 2011AA ValueDomain)
    C25463 (NCI Thesaurus ValueDomain-2)
    C0750480 (UMLS 2011AA ValueDomain-2)
    Item
    ISS stage
    text
    C3242 (NCI Thesaurus ObjectClass)
    C0026764 (UMLS 2011AA ObjectClass)
    C2991 (NCI Thesaurus ObjectClass-2)
    C0012634 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C16899 (NCI Thesaurus Property-2)
    C1300072 (UMLS 2011AA Property-2)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    ISS stage
    CL Item
    I (I)
    CL Item
    Ii (II)
    CL Item
    Iii (III)
    PersonAncillaryStudyRegistrationText
    Item
    If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    C16041 (NCI Thesaurus Property-2)
    C1515980 (UMLS 2011AA Property-2)
    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2
    Item
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C15207 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus Property-3)
    C0022885 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PersonSpecimenMalignantNeoplasmResearchConsentInd-2
    Item
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C9305 (NCI Thesaurus Property-2)
    C0006826 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-3)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2
    Item
    My specimens may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C12801 (NCI Thesaurus Property)
    C0040300 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-2)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientAdditionalResearchConsentInd-2
    Item
    Someone from this institution may contact me in the future to ask me to take part in more research.
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C25406 (NCI Thesaurus Property-2)
    C1524062 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item Group
    Patient Demographics / Pre-treatment Characteristics
    Item
    Patient's Sex
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C28421 (NCI Thesaurus Property)
    C1522384 (UMLS 2011AA Property)
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ValueDomain-2)
    C0030705 (UMLS 2011AA ValueDomain-2)
    C28421 (NCI Thesaurus ValueDomain-3)
    C1522384 (UMLS 2011AA ValueDomain-3)
    CL.10
    Code List
    Patient's Sex
    CL Item
    Male (M)
    C20197 (NCI Thesaurus)
    C0086582 (UMLS 2011AA)
    CL Item
    Female (F)
    C16576 (NCI Thesaurus)
    C0086287 (UMLS 2011AA)
    Birth Date
    Item
    Birthdate (mm/yy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0421451 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25155 (NCI Thesaurus Property)
    Item
    Patient's Race
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0034510 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17049 (NCI Thesaurus Property)
    CL.11
    Code List
    Patient's Race
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
    C41259 (NCI Thesaurus)
    C1515945 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
    C41260 (NCI Thesaurus)
    C0078988 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
    C16352 (NCI Thesaurus)
    C0085756 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
    C41219 (NCI Thesaurus)
    C1513907 (UMLS 2011AA)
    CL Item
    Not Provided Or Available (Not Reported)
    C43234 (NCI Thesaurus)
    C1706613 (UMLS 2011AA)
    CL Item
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
    C41261 (NCI Thesaurus)
    C0007457 (UMLS 2011AA)
    AddressPostalCodeIdentifier
    Item
    ZIP Code
    text
    C25407 (NCI Thesaurus ObjectClass)
    C1442065 (UMLS 2011AA ObjectClass)
    C25621 (NCI Thesaurus Property)
    C1514254 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus ValueDomain)
    C0600091 (UMLS 2011AA ValueDomain)
    C25407 (NCI Thesaurus ValueDomain-2)
    C1442065 (UMLS 2011AA ValueDomain-2)
    C25621 (NCI Thesaurus ValueDomain-3)
    C1514254 (UMLS 2011AA ValueDomain-3)
    Item
    Patient Ethnicity
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0015031 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C16564 (NCI Thesaurus Property)
    CL.12
    Code List
    Patient Ethnicity
    CL Item
    A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)
    C17459 (NCI Thesaurus)
    C0086409 (UMLS 2011AA)
    CL Item
    A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
    C41222 (NCI Thesaurus)
    C1518424 (UMLS 2011AA)
    CL Item
    Not Provided Or Available (Not reported)
    C43234 (NCI Thesaurus)
    C1706613 (UMLS 2011AA)
    CL Item
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Medical Record Number
    Item
    Patient Hospital No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301894 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    Social Security Number
    Item
    Patient Social Security Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301821 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25686 (NCI Thesaurus Property)
    Item
    Method of payment (check one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25371 (NCI Thesaurus Property)
    C0680264 (UMLS 2011AA Property)
    C25541 (NCI Thesaurus Property-2)
    C1512888 (UMLS 2011AA Property-2)
    CL.13
    Code List
    Method of payment (check one)
    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, Not Otherwise Specified (NOS))
    CL Item
    Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
    CL Item
    Veterans Sponsored (Veterans Sponsored)
    CL Item
    Self Pay (no Insurance) (Self Pay (No Insurance))
    CL Item
    No Means Of Payment (no Insurance) (No means of payment (no insurance))
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Country of residence
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25407 (NCI Thesaurus Property)
    C1442065 (UMLS 2011AA Property)
    CL.14
    Code List
    Country of residence
    CL Item
    Ascension Island (AC)
    CL Item
    Andorra (AD)
    C16289 (NCI Thesaurus)
    C0002838 (UMLS 2011AA)
    CL Item
    United Arab Emirates (AE)
    C17232 (NCI Thesaurus)
    C0041698 (UMLS 2011AA)
    CL Item
    Afghanistan (AF)
    C16267 (NCI Thesaurus)
    C0001732 (UMLS 2011AA)
    CL Item
    Antigua And Barbuda (AG)
    C16303 (NCI Thesaurus)
    C0003354 (UMLS 2011AA)
    CL Item
    Anguilla (AI)
    C20133 (NCI Thesaurus)
    C0003353 (UMLS 2011AA)
    CL Item
    Albania (AL)
    CL Item
    Armenia (AM)
    C16306 (NCI Thesaurus)
    C0003798 (UMLS 2011AA)
    CL Item
    Netherland Antilles (AN)
    CL Item
    Angola (AO)
    C16292 (NCI Thesaurus)
    C0003023 (UMLS 2011AA)
    CL Item
    Antarctica (AQ)
    C18007 (NCI Thesaurus)
    C0454691 (UMLS 2011AA)
    CL Item
    Argentina (AR)
    C16305 (NCI Thesaurus)
    C0003761 (UMLS 2011AA)
    CL Item
    American Samoa (AS)
    C17739 (NCI Thesaurus)
    C0242536 (UMLS 2011AA)
    CL Item
    Austria (AT)
    C16312 (NCI Thesaurus)
    C0004348 (UMLS 2011AA)
    CL Item
    Australia (AU)
    C16311 (NCI Thesaurus)
    C0004340 (UMLS 2011AA)
    CL Item
    Aruba (AW)
    C17884 (NCI Thesaurus)
    C0282379 (UMLS 2011AA)
    CL Item
    Azerbaidjan (AZ)
    CL Item
    Bosnia-herzegovina (BA)
    C16361 (NCI Thesaurus)
    C0006036 (UMLS 2011AA)
    CL Item
    Barbados (BB)
    C16324 (NCI Thesaurus)
    C0004739 (UMLS 2011AA)
    CL Item
    Bangladesh (BD)
    C16323 (NCI Thesaurus)
    C0004732 (UMLS 2011AA)
    CL Item
    Belgium (BE)
    C16329 (NCI Thesaurus)
    C0004950 (UMLS 2011AA)
    CL Item
    Burkina Faso (BF)
    C16369 (NCI Thesaurus)
    C0006409 (UMLS 2011AA)
    CL Item
    Bulgaria (BG)
    C16368 (NCI Thesaurus)
    C0006368 (UMLS 2011AA)
    CL Item
    Bahrain (BH)
    C16322 (NCI Thesaurus)
    C0004684 (UMLS 2011AA)
    CL Item
    Burundi (BI)
    C16371 (NCI Thesaurus)
    C0006448 (UMLS 2011AA)
    CL Item
    Benin (BJ)
    CL Item
    Bermuda (BM)
    C16334 (NCI Thesaurus)
    C0005126 (UMLS 2011AA)
    CL Item
    Brunei Darussalam (BN)
    C16367 (NCI Thesaurus)
    C0006320 (UMLS 2011AA)
    CL Item
    Bolivia (BO)
    C16359 (NCI Thesaurus)
    C0005918 (UMLS 2011AA)
    CL Item
    Brazil (BR)
    C16364 (NCI Thesaurus)
    C0006137 (UMLS 2011AA)
    CL Item
    Bahamas (BS)
    C16321 (NCI Thesaurus)
    C0004683 (UMLS 2011AA)
    CL Item
    Bhutan (BT)
    C16336 (NCI Thesaurus)
    C0005341 (UMLS 2011AA)
    CL Item
    Bouvet Island (BV)
    C20104 (NCI Thesaurus)
    C1511278 (UMLS 2011AA)
    CL Item
    Botswana (BW)
    C16363 (NCI Thesaurus)
    C0006041 (UMLS 2011AA)
    CL Item
    Belarus (BY)
    C16372 (NCI Thesaurus)
    C0006539 (UMLS 2011AA)
    CL Item
    Belize (BZ)
    C16331 (NCI Thesaurus)
    C0004952 (UMLS 2011AA)
    CL Item
    Canada (CA)
    C16380 (NCI Thesaurus)
    C0006823 (UMLS 2011AA)
    CL Item
    Cocos Isl. (CC)
    CL Item
    Rep. Dem. Congo (CD)
    CL Item
    Central African Rep. (CF)
    CL Item
    Congo (CG)
    C16467 (NCI Thesaurus)
    C0009738 (UMLS 2011AA)
    CL Item
    Switzerland (CH)
    C17181 (NCI Thesaurus)
    C0039021 (UMLS 2011AA)
    CL Item
    Ivory Coast (CI)
    CL Item
    Cook Islands (CK)
    C16469 (NCI Thesaurus)
    C0009956 (UMLS 2011AA)
    CL Item
    Chile (CL)
    CL Item
    Cameroon (CM)
    C16379 (NCI Thesaurus)
    C0006802 (UMLS 2011AA)
    CL Item
    China (CN)
    C16428 (NCI Thesaurus)
    C0008115 (UMLS 2011AA)
    CL Item
    Colombia (CO)
    C16449 (NCI Thesaurus)
    C3245499 (UMLS 2011AA)
    CL Item
    Costa Rica (CR)
    C16470 (NCI Thesaurus)
    C0010182 (UMLS 2011AA)
    CL Item
    Cuba (CU)
    C16477 (NCI Thesaurus)
    C0010435 (UMLS 2011AA)
    CL Item
    Cape Verde (CV)
    C16382 (NCI Thesaurus)
    C0006893 (UMLS 2011AA)
    CL Item
    Christmas Island (CX)
    C44482 (NCI Thesaurus)
    C0006888 (UMLS 2011AA)
    CL Item
    Cyprus (CY)
    C16480 (NCI Thesaurus)
    C0010622 (UMLS 2011AA)
    CL Item
    Czech Republic (CZ)
    C17668 (NCI Thesaurus)
    C0206578 (UMLS 2011AA)
    CL Item
    Germany (DE)
    CL Item
    Djibouti (DJ)
    CL Item
    Denmark (DK)
    CL Item
    Dominica (DM)
    CL Item
    Dominican Republic (DO)
    CL Item
    Algeria (DZ)
    CL Item
    Ecuador (EC)
    CL Item
    Estonia (EE)
    CL Item
    Egypt (EG)
    CL Item
    Western Sahara (EH)
    CL Item
    Eritrea (ER)
    CL Item
    Spain (ES)
    CL Item
    Ethiopia (ET)
    CL Item
    Finland (FI)
    CL Item
    Fiji (FJ)
    CL Item
    Falkland Isl. (FK)
    CL Item
    Micronesia (FM)
    CL Item
    Faroe Islands (FO)
    CL Item
    France (FR)
    CL Item
    France (european Ter.) (FX)
    CL Item
    Gabon (GA)
    CL Item
    Great Britain (GB)
    CL Item
    Grenada (GD)
    CL Item
    Georgia (GE)
    CL Item
    Guiana (fr.) (GF)
    CL Item
    Guernsey (GG)
    CL Item
    Ghana (GH)
    CL Item
    Gibraltar (GI)
    CL Item
    Greenland (GL)
    CL Item
    Gambia (GM)
    CL Item
    Guinea (GN)
    CL Item
    Guadeloupe (fr.) (GP)
    CL Item
    Equatorial Guinea (GQ)
    CL Item
    Greece (GR)
    CL Item
    South Georgia And South Sandwich Islands (GS)
    CL Item
    Guatemala (GT)
    CL Item
    Guam (us) (GU)
    CL Item
    Guinea Bissau (GW)
    CL Item
    Guyana (GY)
    CL Item
    Hong Kong (HK)
    CL Item
    Heard & Mcdonald Isl. (HM)
    CL Item
    Honduras (HN)
    C16694 (NCI Thesaurus)
    C0019905 (UMLS 2011AA)
    CL Item
    Croatia (HR)
    C16474 (NCI Thesaurus)
    C0010343 (UMLS 2011AA)
    CL Item
    Haiti (HT)
    C16660 (NCI Thesaurus)
    C0018510 (UMLS 2011AA)
    CL Item
    Hungary (HU)
    C16699 (NCI Thesaurus)
    C0020174 (UMLS 2011AA)
    CL Item
    Indonesia (ID)
    C16728 (NCI Thesaurus)
    C0021247 (UMLS 2011AA)
    CL Item
    Ireland (IE)
    C16757 (NCI Thesaurus)
    C0022067 (UMLS 2011AA)
    CL Item
    Israel (IL)
    C16760 (NCI Thesaurus)
    C0022271 (UMLS 2011AA)
    CL Item
    Isle Of Man (IM)
    C0022132 (NCI Metathesaurus)
    CL Item
    India (IN)
    C16727 (NCI Thesaurus)
    C0021201 (UMLS 2011AA)
    CL Item
    British Indian O. Ter. (IO)
    CL Item
    Iraq (IQ)
    C16756 (NCI Thesaurus)
    C0022066 (UMLS 2011AA)
    CL Item
    Iran (IR)
    C16755 (NCI Thesaurus)
    C0022065 (UMLS 2011AA)
    CL Item
    Iceland (IS)
    C16704 (NCI Thesaurus)
    C0020750 (UMLS 2011AA)
    CL Item
    Italy (IT)
    C16761 (NCI Thesaurus)
    C0022277 (UMLS 2011AA)
    CL Item
    Jersey (JE)
    CL Item
    Jamaica (JM)
    C16763 (NCI Thesaurus)
    C0022337 (UMLS 2011AA)
    CL Item
    Jordan (JO)
    C16765 (NCI Thesaurus)
    C0022418 (UMLS 2011AA)
    CL Item
    Japan (JP)
    C16764 (NCI Thesaurus)
    C0022341 (UMLS 2011AA)
    CL Item
    Kenya (KE)
    C16769 (NCI Thesaurus)
    C0022558 (UMLS 2011AA)
    CL Item
    Kyrgyz Republic (KG)
    CL Item
    Cambodia (KH)
    C16378 (NCI Thesaurus)
    C0006797 (UMLS 2011AA)
    CL Item
    Kiribati (KI)
    C16639 (NCI Thesaurus)
    C0017550 (UMLS 2011AA)
    CL Item
    Comoros (KM)
    C16458 (NCI Thesaurus)
    C0009490 (UMLS 2011AA)
    CL Item
    St. Kitts Nevis Anguilla (KN)
    CL Item
    Korea (north) (KP)
    CL Item
    Korea (south) (KR)
    CL Item
    Kuwait (KW)
    C16775 (NCI Thesaurus)
    C0022804 (UMLS 2011AA)
    CL Item
    Cayman Islands (KY)
    C16391 (NCI Thesaurus)
    C0007481 (UMLS 2011AA)
    CL Item
    Kazakstan (KZ)
    CL Item
    Laos (LA)
    CL Item
    Lebanon (LB)
    C16784 (NCI Thesaurus)
    C0023190 (UMLS 2011AA)
    CL Item
    Saint Lucia (LC)
    C17113 (NCI Thesaurus)
    C0036056 (UMLS 2011AA)
    CL Item
    Liechtenstein (LI)
    C16794 (NCI Thesaurus)
    C0023668 (UMLS 2011AA)
    CL Item
    Sri Lanka (LK)
    C17163 (NCI Thesaurus)
    C0038088 (UMLS 2011AA)
    CL Item
    Liberia (LR)
    C16791 (NCI Thesaurus)
    C0023617 (UMLS 2011AA)
    CL Item
    Lesotho (LS)
    CL Item
    Lithuania (LT)
    C16799 (NCI Thesaurus)
    C0023879 (UMLS 2011AA)
    CL Item
    Luxembourg (LU)
    C16803 (NCI Thesaurus)
    C0024176 (UMLS 2011AA)
    CL Item
    Latvia (LV)
    C16783 (NCI Thesaurus)
    C0023128 (UMLS 2011AA)
    CL Item
    Libya (LY)
    CL Item
    Morocco (MA)
    C16878 (NCI Thesaurus)
    C0026544 (UMLS 2011AA)
    CL Item
    Monaco (MC)
    C16874 (NCI Thesaurus)
    C0026405 (UMLS 2011AA)
    CL Item
    Moldova (MD)
    C16871 (NCI Thesaurus)
    C0026374 (UMLS 2011AA)
    CL Item
    Madagascar (MG)
    C16808 (NCI Thesaurus)
    C0024443 (UMLS 2011AA)
    CL Item
    Marshall Islands (MH)
    C16822 (NCI Thesaurus)
    C0024851 (UMLS 2011AA)
    CL Item
    Macedonia (MK)
    C0700290 (NCI Metathesaurus)
    CL Item
    Mali (ML)
    C16816 (NCI Thesaurus)
    C0024581 (UMLS 2011AA)
    CL Item
    Myanmar (MM)
    C16370 (NCI Thesaurus)
    C0006416 (UMLS 2011AA)
    CL Item
    Mongolia (MN)
    C16875 (NCI Thesaurus)
    C0026410 (UMLS 2011AA)
    CL Item
    Macau (MO)
    C16807 (NCI Thesaurus)
    C0024403 (UMLS 2011AA)
    CL Item
    Northern Mariana Isl. (MP)
    CL Item
    Martinique (fr.) (MQ)
    CL Item
    Mauritania (MR)
    C16826 (NCI Thesaurus)
    C0024943 (UMLS 2011AA)
    CL Item
    Montserrat (MS)
    C16876 (NCI Thesaurus)
    C0026514 (UMLS 2011AA)
    CL Item
    Malta (MT)
    C16817 (NCI Thesaurus)
    C0024653 (UMLS 2011AA)
    CL Item
    Mauritius (MU)
    C16827 (NCI Thesaurus)
    C0024944 (UMLS 2011AA)
    CL Item
    Maldives (MV)
    C16815 (NCI Thesaurus)
    C0024553 (UMLS 2011AA)
    CL Item
    Malawi (MW)
    C16813 (NCI Thesaurus)
    C0024548 (UMLS 2011AA)
    CL Item
    Mexico (MX)
    C16850 (NCI Thesaurus)
    C0025885 (UMLS 2011AA)
    CL Item
    Malaysia (MY)
    C16814 (NCI Thesaurus)
    C0024552 (UMLS 2011AA)
    CL Item
    Mozambique (MZ)
    C16882 (NCI Thesaurus)
    C0026655 (UMLS 2011AA)
    CL Item
    Namibia (NA)
    C16891 (NCI Thesaurus)
    C0027366 (UMLS 2011AA)
    CL Item
    New Caledonia (fr.) (NC)
    CL Item
    Niger (NE)
    C16916 (NCI Thesaurus)
    C0028074 (UMLS 2011AA)
    CL Item
    Norfolk Island (NF)
    C16919 (NCI Thesaurus)
    C0028366 (UMLS 2011AA)
    CL Item
    Nigeria (NG)
    C16917 (NCI Thesaurus)
    C0028075 (UMLS 2011AA)
    CL Item
    Nicaragua (NI)
    C16915 (NCI Thesaurus)
    C0028002 (UMLS 2011AA)
    CL Item
    Netherlands (NL)
    C16903 (NCI Thesaurus)
    C0027778 (UMLS 2011AA)
    CL Item
    Norway (NO)
    C16920 (NCI Thesaurus)
    C0028423 (UMLS 2011AA)
    CL Item
    Nepal (NP)
    C16901 (NCI Thesaurus)
    C0027689 (UMLS 2011AA)
    CL Item
    Nauru (NR)
    C16896 (NCI Thesaurus)
    C0027496 (UMLS 2011AA)
    CL Item
    Niue (NU)
    C16918 (NCI Thesaurus)
    C0028219 (UMLS 2011AA)
    CL Item
    New Zealand (NZ)
    C16914 (NCI Thesaurus)
    C0027978 (UMLS 2011AA)
    CL Item
    Oman (OM)
    C16933 (NCI Thesaurus)
    C0028971 (UMLS 2011AA)
    CL Item
    Other (Other)
    CL Item
    Panama (PA)
    C16951 (NCI Thesaurus)
    C0030266 (UMLS 2011AA)
    CL Item
    Peru (PE)
    C16972 (NCI Thesaurus)
    C0031238 (UMLS 2011AA)
    CL Item
    Polynesia (fr.) (PF)
    CL Item
    Papua New Guinea (PG)
    C16952 (NCI Thesaurus)
    C0030375 (UMLS 2011AA)
    CL Item
    Philippines (PH)
    CL Item
    Pakistan (PK)
    C16949 (NCI Thesaurus)
    C0030211 (UMLS 2011AA)
    CL Item
    Poland (PL)
    C17002 (NCI Thesaurus)
    C0032356 (UMLS 2011AA)
    CL Item
    St. Pierre & Miquelon (PM)
    CL Item
    Pitcairn (PN)
    C16993 (NCI Thesaurus)
    C0031995 (UMLS 2011AA)
    CL Item
    Puerto Rico (PR)
    C17043 (NCI Thesaurus)
    C0034044 (UMLS 2011AA)
    CL Item
    Portugal (PT)
    C17006 (NCI Thesaurus)
    C0032729 (UMLS 2011AA)
    CL Item
    Palau (PW)
    C17733 (NCI Thesaurus)
    C0242397 (UMLS 2011AA)
    CL Item
    Paraguay (PY)
    C16953 (NCI Thesaurus)
    C0030428 (UMLS 2011AA)
    CL Item
    Qatar (QA)
    C17045 (NCI Thesaurus)
    C0034366 (UMLS 2011AA)
    CL Item
    Reunion (fr.) (RE)
    CL Item
    Romania (RO)
    C17108 (NCI Thesaurus)
    C0035826 (UMLS 2011AA)
    CL Item
    Russian Federation (RU)
    CL Item
    Rwanda (RW)
    C17112 (NCI Thesaurus)
    C0035978 (UMLS 2011AA)
    CL Item
    Saudi Arabia (SA)
    C17117 (NCI Thesaurus)
    C0036243 (UMLS 2011AA)
    CL Item
    Solomon Islands (SB)
    C17148 (NCI Thesaurus)
    C0037623 (UMLS 2011AA)
    CL Item
    Seychelles (SC)
    C17129 (NCI Thesaurus)
    C0036919 (UMLS 2011AA)
    CL Item
    Sudan (SD)
    C17170 (NCI Thesaurus)
    C0038642 (UMLS 2011AA)
    CL Item
    Sweden (SE)
    C17180 (NCI Thesaurus)
    C0038995 (UMLS 2011AA)
    CL Item
    Singapore (SG)
    C17134 (NCI Thesaurus)
    C0037173 (UMLS 2011AA)
    CL Item
    St. Helena (SH)
    CL Item
    Slovenia (SI)
    C17138 (NCI Thesaurus)
    C0037334 (UMLS 2011AA)
    CL Item
    Svalbard & Jan Mayen Isl. (SJ)
    CL Item
    Slovakia (SK)
    C17669 (NCI Thesaurus)
    C0206579 (UMLS 2011AA)
    CL Item
    Sierra Leone (SL)
    C17130 (NCI Thesaurus)
    C0037063 (UMLS 2011AA)
    CL Item
    San Marino (SM)
    C17115 (NCI Thesaurus)
    C0036154 (UMLS 2011AA)
    CL Item
    Senegal (SN)
    C17121 (NCI Thesaurus)
    C0036644 (UMLS 2011AA)
    CL Item
    Somalia (SO)
    C17149 (NCI Thesaurus)
    C0037640 (UMLS 2011AA)
    CL Item
    Suriname (SR)
    C17175 (NCI Thesaurus)
    C0038944 (UMLS 2011AA)
    CL Item
    St. Tome And Principe (ST)
    CL Item
    Soviet Union (SU)
    CL Item
    El Salvador (SV)
    C16532 (NCI Thesaurus)
    C0013754 (UMLS 2011AA)
    CL Item
    Syria (SY)
    C17182 (NCI Thesaurus)
    C0039138 (UMLS 2011AA)
    CL Item
    Swaziland (SZ)
    C17179 (NCI Thesaurus)
    C0038983 (UMLS 2011AA)
    CL Item
    Turks & Caicos Islands (TC)
    CL Item
    Chad (TD)
    C16412 (NCI Thesaurus)
    C0007928 (UMLS 2011AA)
    CL Item
    French Southern Terr. (TF)
    CL Item
    Togo (TG)
    C17202 (NCI Thesaurus)
    C0040363 (UMLS 2011AA)
    CL Item
    Thailand (TH)
    C17192 (NCI Thesaurus)
    C0039725 (UMLS 2011AA)
    CL Item
    Tadjikistan (TJ)
    CL Item
    Tokelau (TK)
    C17704 (NCI Thesaurus)
    C0220928 (UMLS 2011AA)
    CL Item
    Turkmenistan (TM)
    C17223 (NCI Thesaurus)
    C0041403 (UMLS 2011AA)
    CL Item
    Tunisia (TN)
    C17221 (NCI Thesaurus)
    C0041388 (UMLS 2011AA)
    CL Item
    Tonga (TO)
    CL Item
    East Timor (TP)
    C17200 (NCI Thesaurus)
    C1452561 (UMLS 2011AA)
    CL Item
    Turkey (TR)
    C17222 (NCI Thesaurus)
    C0041400 (UMLS 2011AA)
    CL Item
    Trinidad & Tobago (TT)
    CL Item
    Tuvalu (TV)
    C17225 (NCI Thesaurus)
    C0041413 (UMLS 2011AA)
    CL Item
    Taiwan (TW)
    C17184 (NCI Thesaurus)
    C0039260 (UMLS 2011AA)
    CL Item
    Tanzania (TZ)
    C17185 (NCI Thesaurus)
    C0039298 (UMLS 2011AA)
    CL Item
    Ukraine (UA)
    C17229 (NCI Thesaurus)
    C0041580 (UMLS 2011AA)
    CL Item
    Uganda (UG)
    C17228 (NCI Thesaurus)
    C0041573 (UMLS 2011AA)
    CL Item
    United Kingdom (UK)
    C17233 (NCI Thesaurus)
    C0041700 (UMLS 2011AA)
    CL Item
    Us Minor Outlying Isl. (UM)
    CL Item
    Usa (US)
    CL Item
    Uruguay (UY)
    C17244 (NCI Thesaurus)
    C0042113 (UMLS 2011AA)
    CL Item
    Uzbekistan (UZ)
    C17246 (NCI Thesaurus)
    C0042177 (UMLS 2011AA)
    CL Item
    Vatican City State (VA)
    CL Item
    St. Vincent & Grenadines (VC)
    CL Item
    Venezuela (VE)
    C17250 (NCI Thesaurus)
    C0042469 (UMLS 2011AA)
    CL Item
    Virgin Islands (brit) (VG)
    CL Item
    Virgin Islands (us) (VI)
    CL Item
    Vietnam (VN)
    C17252 (NCI Thesaurus)
    C0042658 (UMLS 2011AA)
    CL Item
    Vanuatu (VU)
    C17247 (NCI Thesaurus)
    C0042321 (UMLS 2011AA)
    CL Item
    Wallis & Futuna Islands (WF)
    CL Item
    Western Samoa (WS)
    CL Item
    Yemen (YE)
    C17264 (NCI Thesaurus)
    C0043402 (UMLS 2011AA)
    CL Item
    Mayotte (YT)
    C16828 (NCI Thesaurus)
    C0024974 (UMLS 2011AA)
    CL Item
    Yugoslavia (YU)
    CL Item
    South Africa (ZA)
    CL Item
    Zambia (ZM)
    C17267 (NCI Thesaurus)
    C0043445 (UMLS 2011AA)
    CL Item
    Dem. Rep. Of Congo (ZR)
    CL Item
    Zimbabwe (ZW)
    C17268 (NCI Thesaurus)
    C0043476 (UMLS 2011AA)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct
    TreatingPhysicianSignatureText
    Item
    Signature of treating physician
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C51883 (NCI Thesaurus ObjectClass)
    C1710470 (UMLS 2011AA ObjectClass)
    TreatingPhysicianSignatureDate
    Item
    Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C51883 (NCI Thesaurus ObjectClass)
    C1710470 (UMLS 2011AA ObjectClass)
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