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ID

42980

Descrição

E2905 Registration Worksheet (step 1) Lenalidomide With or Without Epoetin Alfa in Treating Patients With Myelodysplastic Syndrome and Anemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=532F2F3F-8CD5-5A3D-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=532F2F3F-8CD5-5A3D-E044-0003BA3F9857

Palavras-chave

Versões (3)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 17/09/2021 17/09/2021 -
Transferido a

17 de setembro de 2021

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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    Leukemia NCT00843882 Eligibility - E2905 Registration Worksheet (step 1) - 2769395v1.0

    Inglês

    No Instruction available.

    1 Formulários  
    1. StudyEvent: E2905 Registration Worksheet (step 1)
      1. No Instruction available.
    Eligibility
    Descrição

    Eligibility

    First initial
    Descrição

    Patient Initials First

    Tipo de dados

    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
    Descrição

    Patient Initials Last

    Tipo de dados

    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
    Descrição

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Tipo de dados

    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?
    Descrição

    Eligibility for trial

    Tipo de dados

    boolean

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

    Consent signed

    Tipo de dados

    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
    Descrição

    InformedConsentFormSignedDate

    Tipo de dados

    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
    Descrição

    HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

    Tipo de dados

    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
    Descrição

    PatientSignedDischargeMedicalRecordDate

    Tipo de dados

    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
    Serum EPO Level (mU/ml)
    Descrição

    SerumErythropoietinLevelAmount

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C13325
    UMLS 2011AA ObjectClass
    C0229671
    NCI Thesaurus Property
    C20429
    UMLS 2011AA Property
    C0014822
    NCI Thesaurus ValueDomain
    C25417
    NCI Thesaurus Property-2
    C25554
    UMLS 2011AA Property-2
    C0441889
    Prior erythropoietic growth factor
    Descrição

    AgentPriorErythropoietinAdministrationType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property-2
    C20429
    UMLS 2011AA Property-2
    C0014822
    NCI Thesaurus Property-3
    C25409
    UMLS 2011AA Property-3
    C1533734
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Del 5131-33 karotype
    Descrição

    LaboratoryProcedureDeletionAbnormality5q31OutcomeInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C13385
    UMLS 2011AA Property-2
    C0796362
    NCI Thesaurus Property-3
    C45577
    UMLS 2011AA Property-3
    C1704790
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    Descrição

    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

    Tipo de dados

    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.
    Descrição

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Tipo de dados

    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 research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    Descrição

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Tipo de dados

    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.
    Descrição

    PatientAdditionalResearchConsentInd-2

    Tipo de dados

    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
    Name of local cytogenetics lab
    Descrição

    CytogeneticsLaboratoryIdentifierName

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C16487
    UMLS 2011AA ObjectClass
    C0010802
    NCI Thesaurus ObjectClass-2
    C37984
    UMLS 2011AA ObjectClass-2
    C0022877
    Phone number
    Descrição

    CytogeneticsLaboratoryCommunicationContactTelephoneNumber

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C16487
    UMLS 2011AA ObjectClass
    C0010802
    NCI Thesaurus ObjectClass-2
    C37984
    UMLS 2011AA ObjectClass-2
    C0022877
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    NCI Thesaurus Property-2
    C47954
    UMLS 2011AA Property-2
    C1705415
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Patient Demographics / Pre-treatment Characteristics
    Descrição

    Patient Demographics / Pre-treatment Characteristics

    Patient's Sex
    Descrição

    PatientSexCode

    Tipo de dados

    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)
    Descrição

    Birth Date

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0421451
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25155
    Patient Race (check all that applyU.S. and Canada only)
    Descrição

    Racial Group

    Tipo de dados

    text

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

    AddressPostalCodeIdentifier

    Tipo de dados

    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
    Descrição

    Ethnic Group

    Tipo de dados

    text

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

    Medical Record Number

    Tipo de dados

    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
    Descrição

    Social Security Number

    Tipo de dados

    text

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

    PatientInternationalPaymentType

    Tipo de dados

    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
    Attending Physician
    Descrição

    AttendingPhysicianIdentifierIndividualsName

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Metathesaurus ObjectClass
    CL317115
    Institution contact
    Descrição

    InstitutionContactPersonName

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass-2
    C25461
    UMLS 2011AA ObjectClass-2
    C0337611
    Registrar
    Descrição

    Protocol Registrar

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS CUI-2
    C0557514
    NCI Thesaurus ObjectClass
    C25357
    Country of Residence
    Descrição

    Country of current residence

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C3258975
    NCI Thesaurus ValueDomain
    C25464
    NCI Thesaurus Property
    C25407
    NCI Thesaurus ValueDomain-2
    C42614
    Comments
    Descrição

    Research Comments

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Signature of treating physician (I have reviewed the above data and agree the date are accurate and correct)
    Descrição

    TreatingPhysicianSignatureText

    Tipo de dados

    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 (Note: Date must be on or before date of registration)
    Descrição

    TreatingPhysicianSignatureDate

    Tipo de dados

    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 Formulários
    1. StudyEvent: E2905 Registration Worksheet (step 1)
      1. No Instruction available.
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    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)
    SerumErythropoietinLevelAmount
    Item
    Serum EPO Level (mU/ml)
    text
    C13325 (NCI Thesaurus ObjectClass)
    C0229671 (UMLS 2011AA ObjectClass)
    C20429 (NCI Thesaurus Property)
    C0014822 (UMLS 2011AA Property)
    C25417 (NCI Thesaurus ValueDomain)
    C25554 (NCI Thesaurus Property-2)
    C0441889 (UMLS 2011AA Property-2)
    Item
    Prior erythropoietic growth factor
    text
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C20429 (NCI Thesaurus Property-2)
    C0014822 (UMLS 2011AA Property-2)
    C25409 (NCI Thesaurus Property-3)
    C1533734 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Prior erythropoietic growth factor
    CL Item
    Erythropoietin (Prior erythropoietin/DA)
    C20429 (NCI Thesaurus)
    C0014822 (UMLS 2011AA)
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    LaboratoryProcedureDeletionAbnormality5q31OutcomeInd-2
    Item
    Del 5131-33 karotype
    boolean
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C13385 (NCI Thesaurus Property-2)
    C0796362 (UMLS 2011AA Property-2)
    C45577 (NCI Thesaurus Property-3)
    C1704790 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    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 research about other health problems (for example: causes of diabetes, Alzheimer's disease, and 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)
    CytogeneticsLaboratoryIdentifierName
    Item
    Name of local cytogenetics lab
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C16487 (NCI Thesaurus ObjectClass)
    C0010802 (UMLS 2011AA ObjectClass)
    C37984 (NCI Thesaurus ObjectClass-2)
    C0022877 (UMLS 2011AA ObjectClass-2)
    CytogeneticsLaboratoryCommunicationContactTelephoneNumber
    Item
    Phone number
    text
    C16487 (NCI Thesaurus ObjectClass)
    C0010802 (UMLS 2011AA ObjectClass)
    C37984 (NCI Thesaurus ObjectClass-2)
    C0022877 (UMLS 2011AA ObjectClass-2)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    C47954 (NCI Thesaurus Property-2)
    C1705415 (UMLS 2011AA Property-2)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (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.11
    Code List
    Patient's Sex
    CL Item
    Female (F)
    C16576 (NCI Thesaurus)
    C0086287 (UMLS 2011AA)
    CL Item
    Male (M)
    C20197 (NCI Thesaurus)
    C0086582 (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 Race (check all that applyU.S. and Canada only)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0034510 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17049 (NCI Thesaurus Property)
    CL.12
    Code List
    Patient Race (check all that applyU.S. and Canada only)
    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
    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 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
    Not Provided Or Available (Not Reported)
    C43234 (NCI Thesaurus)
    C1706613 (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 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
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (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.13
    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.14
    Code List
    Method of payment (check one)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    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
    National Health Service (National Health Service)
    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
    Private Insurance (Private Insurance)
    CL Item
    Self Pay (no Insurance) (Self Pay (No Insurance))
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Veterans Sponsored (Veterans Sponsored)
    AttendingPhysicianIdentifierIndividualsName
    Item
    Attending Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CL317115 (NCI Metathesaurus ObjectClass)
    InstitutionContactPersonName
    Item
    Institution contact
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25461 (NCI Thesaurus ObjectClass-2)
    C0337611 (UMLS 2011AA ObjectClass-2)
    Protocol Registrar
    Item
    Registrar
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1507394 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C0557514 (UMLS CUI-2)
    C25357 (NCI Thesaurus ObjectClass)
    Country of current residence
    Item
    Country of Residence
    text
    C16960 (NCI Thesaurus ObjectClass)
    C3258975 (UMLS CUI-1)
    C25464 (NCI Thesaurus ValueDomain)
    C25407 (NCI Thesaurus Property)
    C42614 (NCI Thesaurus ValueDomain-2)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    TreatingPhysicianSignatureText
    Item
    Signature of treating physician (I have reviewed the above data and agree the date are accurate and correct)
    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 (Note: Date must be on or before date of registration)
    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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