Protocol Administration
IRB Approval Date
date
InformedConsentFormSignedDate
date
Treatment Begin Date
date
PatientSignedDischargeMedicalRecordDate
date
InstitutionContactPersonName
text
Person Completing Form Phone
text
ResponsiblePersonFaxNumber
text
Patient Demographics/pre-treatment Characteristics
Patient Initials
text
Patient Birth Date
date
PatientPersonSocialSecurityNumber
text
Medical Record Number
text
Gender
text
Racial Group
text
Ethnic Group
text
Patient Demographics/pre-treatment Characteristics2
PatientAddressPostalCode
text
Country of current residence
text
Certification Of Eligibility And Protocol Design
Eligibility for trial
boolean
PatientQualityofLifeConsentInd-2
boolean
Initial Patient Consent For Specimen Use
SpecimenResearchConsentRelatedInd-3
boolean
BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3
text
Permission to contact Patient
boolean
Registration Information
PatientRegistrationDate
date
Trial subject ID CALGB
text
Trial subject ID Participating Group
text
RegisteringPersonIdentifierSignatureName
text