Protocol Administration
IRB Approval Date
date
InformedConsentFormSignedDate
date
Treatment Begin Date
date
ContactPersonatInstitution
text
Person Completing Form Phone
text
ResponsiblePersonFaxNumber
text
Patient Demographics / Pre-treatment Characteristics
Patient Initials
text
PatientSocialSecurityNumber
text
Patient Birth Date
date
Medical Record Number
text
Gender
text
Racial Group
text
PatientEthnicityCategory
text
PatientPaymentType
text
PatientAddressPostalCode
text
PatientAddressCountryCode
text
Certification Of Eligibility
Protocol Design
Protocol Treatment Arm
text
PatientInitialConsent,Specimen,Patient'scancerresearchInd
boolean
PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
boolean
PatientInitialConsent,Specimen,ContactInd
boolean
Registration Information
Trial subject ID CALGB
text
Trial subject ID Participating Group
text
PatientRegistrationDate
date
Responsible Person Signature
text
Ccrr Module For Calgb 90202 Registration Worksheet