ID

42977

Description

NCCTG N0733 Demography Form Capecitabine and Lapatinib With or Without Cixutumumab in Treating Patients With Previously Treated HER2-Positive Stage IIIB, Stage IIIC, or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=643B1D4E-2802-CA4C-E040-BB89AD432C8F

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=643B1D4E-2802-CA4C-E040-BB89AD432C8F

Keywords

Versions (4)
  1. 8/27/12 8/27/12 -
  2. 3/24/14 3/24/14 - Martin Dugas
  3. 3/24/14 3/24/14 - Martin Dugas
  4. 9/17/21 9/17/21 -
Uploaded on

September 17, 2021

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00684983 Demographic - NCCTG N0733 Demography Form - 2842806v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: NCCTG N0733 Demography Form
    1. No Instruction available.
Standard Patient Identifier
Description

Standard Patient Identifier

Alias
UMLS CUI-1
CL386173
Patient Initials LastName
Description

Patient initials last name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NCI Thesaurus Property
C25551
UMLS CUI-1
C2986440
Patient initials first name
Description

Patient initials first name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NCI Thesaurus Property
C25509
UMLS CUI-1
C2986440
Patient initials middle name
Description

Patient initials middle name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NCI Thesaurus Property
C25569
UMLS CUI-1
C2986440
Patient SSN
Description

Social security number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25686
UMLS CUI-1
C1301821
Patient Medical Record Number
Description

Medical Record Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property
C25198
UMLS CUI-1
C1301894
Standard Demographics
Description

Standard Demographics

Alias
UMLS CUI-1
C1704791
Ethnicity
Description

Ethnicity

Data type

text

Alias
NCI Thesaurus Property
C25372
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C16564
UMLS CUI-1
C0015031
Gender of a Person
Description

Gender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C17357
UMLS CUI-1
C0079399
Patient's Date of Birth
Description

Birth Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C25155
UMLS CUI-1
C0421451
2000 Census Tract Codes
Description

Census Tract Codes

Data type

text

Alias
NCI Thesaurus ObjectClass
C16495
NCI Thesaurus Property
C67490
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain
C25407
NCI Thesaurus ValueDomain
C67490
Patient's Country of Residence
Description

Country

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25464
NCI Thesaurus Property
C25407
NCI Thesaurus ValueDomain
C42614
UMLS CUI-1
C1562954
Patient's ZIP Code
Description

Postal Code

Data type

text

Alias
NCI Thesaurus ObjectClass
C25407
NCI Thesaurus Property
C25621
NCI Thesaurus ValueDomain
C25364
NCI Thesaurus ValueDomain
C25407
NCI Thesaurus ValueDomain
C25621
UMLS CUI-1
C0421454
Race
Description

Race

Alias
UMLS CUI-1
C0034510
Race Category
Description

Race

Data type

text

Alias
NCI Thesaurus Property
C25372
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C17049
UMLS CUI-1
C0034510
Method Of Payment
Description

Method Of Payment

Alias
UMLS CUI-1
C0680264
Method of Payment
Description

Payment Method

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus Property
C16847
NCI Thesaurus ObjectClass
C25371
UMLS CUI-1
C0680264
Optional Questions
Description

Optional Questions

Alias
UMLS CUI-1
C1518600
UMLS CUI-2
C1522634
CDC Race Code
Description

CDC Race Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus Property
C25372
NCI Thesaurus ObjectClass
C17049
UMLS CUI-1
C0007670
UMLS CUI-2
C0034510
CDC Ethnicity Code
Description

CDC Ethnicity Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus Property
C25372
NCI Thesaurus ObjectClass
C16564
UMLS CUI-1
C0007670
UMLS CUI-2
C0015031
Education Level
Description

Educational Status

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C17953
NCI Thesaurus ValueDomain
C17953
UMLS CUI-1
C0013658
Marital Status
Description

Marital Status

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus Property
C25188
UMLS CUI-1
C0024819
Place of Birth
Description

Birth Place

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C25155
NCI Thesaurus Property
C25319
NCI Thesaurus Property
C37957
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain
C25155
NCI Thesaurus ValueDomain
C25319
UMLS CUI-1
C0032040
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No Instruction available.

1 forms
  1. StudyEvent: NCCTG N0733 Demography Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Standard Patient Identifier
CL386173 (UMLS CUI-1)
Patient initials last name
Item
Patient Initials LastName
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient initials first name
Item
Patient initials first name
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient initials middle name
Item
Patient initials middle name
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C25569 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Social security number
Item
Patient SSN
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25686 (NCI Thesaurus Property)
C1301821 (UMLS CUI-1)
Medical Record Number
Item
Patient Medical Record Number
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property)
C1301894 (UMLS CUI-1)
Item Group
Standard Demographics
C1704791 (UMLS CUI-1)
Item
Ethnicity
text
C25372 (NCI Thesaurus Property)
C25372 (NCI Thesaurus ValueDomain)
C16564 (NCI Thesaurus ObjectClass)
C0015031 (UMLS CUI-1)
CL.1
Code List
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)
Item
Gender of a Person
text
C25284 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI-1)
CL.2
Code List
Gender of a Person
CL Item
Female Gender (Female Gender)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
CL Item
Male Gender (Male Gender)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Unspecified (Unspecified)
C38046 (NCI Thesaurus)
C0205370 (UMLS 2011AA)
Birth Date
Item
Patient's Date of Birth
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
Census Tract Codes
Item
2000 Census Tract Codes
text
C16495 (NCI Thesaurus ObjectClass)
C67490 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C25704 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C67490 (NCI Thesaurus ValueDomain)
Country
Item
Patient's Country of Residence
text
C16960 (NCI Thesaurus ObjectClass)
C25464 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus Property)
C42614 (NCI Thesaurus ValueDomain)
C1562954 (UMLS CUI-1)
Postal Code
Item
Patient's ZIP Code
text
C25407 (NCI Thesaurus ObjectClass)
C25621 (NCI Thesaurus Property)
C25364 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C25621 (NCI Thesaurus ValueDomain)
C0421454 (UMLS CUI-1)
Item Group
Race
C0034510 (UMLS CUI-1)
Item
Race Category
text
C25372 (NCI Thesaurus Property)
C25372 (NCI Thesaurus ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS CUI-1)
CL.3
Code List
Race Category
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
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)
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)
Item Group
Method Of Payment
C0680264 (UMLS CUI-1)
Item
Method of Payment
text
C25162 (NCI Thesaurus ValueDomain)
C16847 (NCI Thesaurus Property)
C25371 (NCI Thesaurus ObjectClass)
C0680264 (UMLS CUI-1)
CL.4
Code List
Method of Payment
CL Item
Private Insurance (1)
CL Item
Medicare (2)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (3)
CL Item
Medicaid (4)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (5)
CL Item
Military Or Veterans Sponsored Nos (6)
CL Item
Military Sponsored (including Champus &tricare) (6a)
CL Item
Veterans Sponsored (6b)
CL Item
Self Pay (no Insurance) (7)
CL Item
No Means Of Payment (no Insurance) (8)
CL Item
Other (98)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (99)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Optional Questions
C1518600 (UMLS CUI-1)
C1522634 (UMLS CUI-2)
CDC Race Code
Item
CDC Race Code
text
C25162 (NCI Thesaurus ValueDomain)
C25372 (NCI Thesaurus Property)
C17049 (NCI Thesaurus ObjectClass)
C0007670 (UMLS CUI-1)
C0034510 (UMLS CUI-2)
CDC Ethnicity Code
Item
CDC Ethnicity Code
text
C25162 (NCI Thesaurus ValueDomain)
C25372 (NCI Thesaurus Property)
C16564 (NCI Thesaurus ObjectClass)
C0007670 (UMLS CUI-1)
C0015031 (UMLS CUI-2)
Item
Education Level
text
C25284 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C17953 (NCI Thesaurus Property)
C17953 (NCI Thesaurus ValueDomain)
C0013658 (UMLS CUI-1)
CL.5
Code List
Education Level
CL Item
Preschool Completion (Preschool)
C70433 (NCI Thesaurus)
C0681405 (UMLS 2011AA)
CL Item
Kindergarten Completion (Kindergarten)
C70432 (NCI Thesaurus)
C0681406 (UMLS 2011AA)
CL Item
1st Grade (1st Grade)
C67123 (NCI Thesaurus)
C1883619 (UMLS 2011AA)
CL Item
2nd Grade (2nd Grade)
C67124 (NCI Thesaurus)
C1883622 (UMLS 2011AA)
CL Item
3rd Grade (3rd Grade)
C67125 (NCI Thesaurus)
C1883635 (UMLS 2011AA)
CL Item
4th Grade (4th Grade)
C67126 (NCI Thesaurus)
C1883642 (UMLS 2011AA)
CL Item
5th Grade (5th Grade)
C67127 (NCI Thesaurus)
C1883646 (UMLS 2011AA)
CL Item
6th Grade (6th Grade)
C67128 (NCI Thesaurus)
C1883649 (UMLS 2011AA)
CL Item
7th Grade (7th Grade)
C67129 (NCI Thesaurus)
C1883651 (UMLS 2011AA)
CL Item
8th Grade (8th Grade)
C67130 (NCI Thesaurus)
C1883653 (UMLS 2011AA)
CL Item
9th Grade (9th Grade)
C67131 (NCI Thesaurus)
C1883654 (UMLS 2011AA)
CL Item
10th Grade (10th Grade)
C67132 (NCI Thesaurus)
C1883613 (UMLS 2011AA)
CL Item
11th Grade (11th Grade)
C67133 (NCI Thesaurus)
C1883614 (UMLS 2011AA)
CL Item
12th Grade (12th Grade No Diploma)
C67134 (NCI Thesaurus)
C1883615 (UMLS 2011AA)
CL Item
High School Graduate (High School Graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS 2011AA)
CL Item
General Equivalency Diploma (General Equivalency Diploma)
C67135 (NCI Thesaurus)
C1880947 (UMLS 2011AA)
CL Item
Bachelor's Degree Completion (Bachelor Degree)
C70555 (NCI Thesaurus)
C2346951 (UMLS 2011AA)
CL Item
Associate Degree (Associate Degree)
C67140 (NCI Thesaurus)
C1879750 (UMLS 2011AA)
CL Item
Academic Doctorate Degree Completion (Academic Doctorate Degree)
C70557 (NCI Thesaurus)
C2348318 (UMLS 2011AA)
CL Item
Master's Degree Completion (Master's Degree)
C70556 (NCI Thesaurus)
C2347079 (UMLS 2011AA)
CL Item
Professional Doctorate Degree Completion (Professional Doctorate Degree)
C70558 (NCI Thesaurus)
C2347690 (UMLS 2011AA)
CL Item
Vocational Degree (VoTech Program)
C67141 (NCI Thesaurus)
C1883542 (UMLS 2011AA)
CL Item
Never Attended (No Formal Schooling)
C67122 (NCI Thesaurus)
C0557286 (UMLS 2011AA)
CL Item
Refuse (Refused)
C49161 (NCI Thesaurus)
C1705116 (UMLS 2011AA)
CL Item
Some College (Some College, No Degree)
C67137 (NCI Thesaurus)
C1883065 (UMLS 2011AA)
CL Item
Does Not Know (Don't Know)
C67142 (NCI Thesaurus)
C1880386 (UMLS 2011AA)
Item
Marital Status
text
C25190 (NCI Thesaurus ObjectClass)
C25372 (NCI Thesaurus ValueDomain)
C25188 (NCI Thesaurus Property)
C0024819 (UMLS CUI-1)
CL.6
Code List
Marital Status
CL Item
Divorced: C51776 (Divorced)
C51776 (NCI Thesaurus)
C0086170 (UMLS 2011AA)
CL Item
Domestic Partner (Domestic Partnership)
C53262 (NCI Thesaurus)
C1549111 (UMLS 2011AA)
CL Item
Married: C51773 (Married)
C51773 (NCI Thesaurus)
C0555047 (UMLS 2011AA)
CL Item
Never Married (Never Married)
C51774 (NCI Thesaurus)
C0027952 (UMLS 2011AA)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS 2011AA)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
Birth Place
Item
Place of Birth
text
C25190 (NCI Thesaurus ObjectClass)
C25155 (NCI Thesaurus Property)
C25319 (NCI Thesaurus Property)
C37957 (NCI Thesaurus Property)
C25704 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus ValueDomain)
C25319 (NCI Thesaurus ValueDomain)
C0032040 (UMLS CUI-1)
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