0 Ratings

ID

43130

Description

Southwest Oncology Group Registration Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF746B-17EF-3705-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF746B-17EF-3705-E034-080020C9C0E0

Keywords

  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    Southwest Oncology Group Registration Form

    No Instruction available.

    1. StudyEvent: Southwest Oncology Group Registration Form
      1. No Instruction available.
    SWOG clinical trial administrative data
    Description

    SWOG clinical trial administrative data

    SWOG Study No.
    Description

    SWOGStudyNo.

    Data type

    text

    Registration Step
    Description

    RegistrationStep

    Data type

    text

    Assigned Treatment Arm
    Description

    TreatmentArmNumber

    Data type

    text

    Activation Date
    Description

    ActivationDate

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C64382
    UMLS 2011AA Property
    C1879547
    NCI Thesaurus Property-2
    C41200
    UMLS 2011AA Property-2
    C0680532
    Last Amended Date
    Description

    DataAmendedLastDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain-2
    C25551
    UMLS 2011AA ValueDomain-2
    C1517741
    Caller's SWOG Roster ID
    Description

    RegistrarSouthwestOncologyGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25699
    UMLS 2011AA Property-2
    C1519429
    NCI Thesaurus ObjectClass
    C25357
    UMLS 2011AA ObjectClass
    C0557514
    SWOG Treating Institution Number
    Description

    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    NCI Thesaurus ObjectClass-3
    C41206
    UMLS 2011AA ObjectClass-3
    C1272753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Date Informed Consent Signed
    Description

    InformedConsentDateSigned

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    SWOG Investigator Number
    Description

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C17089
    UMLS 2011AA ObjectClass-2
    C0035173
    IRB Approval Date
    Description

    IRBApprovalDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25425
    UMLS 2011AA Property
    C0205540
    Projected Start Date of Treatment (Patient Consent for Specimen Use)
    Description

    ProjectedTreatmentBeginDate

    Data type

    date

    patient demographics
    Description

    patient demographics

    Patient's Name
    Description

    Patient'sName

    Data type

    text

    SWOG Patient ID
    Description

    SWOGPatientID

    Data type

    text

    Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Description

    PatientInitialConsent,Specimen,Patient'scancerresearchInd

    Data type

    boolean

    Patient's tissue may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's, and heart disease)
    Description

    PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

    Data type

    boolean

    Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to tak part in more research
    Description

    PatientInitialConsent,Specimen,ContactInd

    Data type

    boolean

    Patient's Date of Birth
    Description

    PatientBirthDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Patient's Sex
    Description

    PatientGender

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17357
    UMLS 2011AA Property
    C0079399
    Method of Payment
    Description

    PaymentMethod

    Data type

    text

    Patient's Ethnicity
    Description

    Patient'sEthnicity

    Data type

    text

    Patient's Race (select all that apply)
    Description

    PatientRace

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    Other, specify (patient's race) (If a U.S. resident)
    Description

    Other,specify(patient'srace)

    Data type

    text

    Patient's Social Security Number
    Description

    PatientSocialSecurityNumber

    Data type

    float

    Patient's Zip Code
    Description

    PatientAddress,PostalCode

    Data type

    float

    Country of Residence, if not USA (If a resident of Canada)
    Description

    PatientAddress,Country

    Data type

    text

    Social Insurance Number
    Description

    PatientSocialInsuranceIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C62650
    UMLS 2011AA ObjectClass-2
    C0728831
    NCI Thesaurus ObjectClass-3
    C16745
    UMLS 2011AA ObjectClass-3
    C0021672
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Postal Code (Statification Factors)
    Description

    AddressPostalCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C25407
    UMLS 2011AA ObjectClass
    C1442065
    NCI Thesaurus Property
    C25621
    UMLS 2011AA Property
    C1514254
    Stage
    Description

    StageGrouping

    Data type

    text

    LDH
    Description

    LDH

    Data type

    text

    Notes
    Description

    Notes

    Notes
    Description

    Comments

    Data type

    text

    Ccrr Module For Southwest Oncology Group Registration Form
    Description

    Ccrr Module For Southwest Oncology Group Registration Form

    Similar models

    No Instruction available.

    1. StudyEvent: Southwest Oncology Group Registration Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    SWOG clinical trial administrative data
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    TreatmentArmNumber
    Item
    Assigned Treatment Arm
    text
    ActivationDate
    Item
    Activation Date
    text
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C64382 (NCI Thesaurus Property)
    C1879547 (UMLS 2011AA Property)
    C41200 (NCI Thesaurus Property-2)
    C0680532 (UMLS 2011AA Property-2)
    DataAmendedLastDate
    Item
    Last Amended Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus ValueDomain-2)
    C1517741 (UMLS 2011AA ValueDomain-2)
    RegistrarSouthwestOncologyGroupIdentifierNumber
    Item
    Caller's SWOG Roster ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property-2)
    C1519429 (UMLS 2011AA Property-2)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS 2011AA ObjectClass)
    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
    Item
    SWOG Treating Institution Number
    float
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    C41206 (NCI Thesaurus ObjectClass-3)
    C1272753 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    InformedConsentDateSigned
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    SouthwestOncologyGroupInvestigatorIdentifierNumber
    Item
    SWOG Investigator Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C17089 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    IRBApprovalDate
    Item
    IRB Approval Date
    date
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25425 (NCI Thesaurus Property)
    C0205540 (UMLS 2011AA Property)
    ProjectedTreatmentBeginDate
    Item
    Projected Start Date of Treatment (Patient Consent for Specimen Use)
    date
    Item Group
    patient demographics
    Patient'sName
    Item
    Patient's Name
    text
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    PatientInitialConsent,Specimen,Patient'scancerresearchInd
    Item
    Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
    boolean
    PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
    Item
    Patient's tissue may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's, and heart disease)
    boolean
    PatientInitialConsent,Specimen,ContactInd
    Item
    Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to tak part in more research
    boolean
    PatientBirthDate
    Item
    Patient's Date of Birth
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    Item
    Patient's Sex
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17357 (NCI Thesaurus Property)
    C0079399 (UMLS 2011AA Property)
    Code List
    Patient's Sex
    CL Item
    Female (Female)
    C46110 (NCI Thesaurus)
    C0086287 (UMLS 2011AA)
    CL Item
    Male (Male)
    C46109 (NCI Thesaurus)
    C1706180 (UMLS 2011AA)
    Item
    Method of Payment
    text
    Code List
    Method of Payment
    CL Item
    Private (Private)
    CL Item
    Medicare (Medicare)
    CL Item
    Medicare and Private (Medicare and Private)
    CL Item
    Medicaid (Medicaid)
    CL Item
    Medicaid and Medicare (Medicaid and Medicare)
    CL Item
    No insurance (self-pay) (No insurance (self-pay))
    CL Item
    No insurance (no means) (No insurance (no means))
    CL Item
    Other, specify at registration (Other, specify at registration)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Veterans Admin (Veterans Admin)
    CL Item
    Military (Military)
    Item
    Patient's Ethnicity
    text
    Code List
    Patient's Ethnicity
    CL Item
    Unknown2006635 (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    No_not_spanish2006636 (No (not Spanish))
    CL Item
    Yes_mexican2006637 (Yes, Mexican)
    CL Item
    Yes_puerto_rican2006638 (Yes, Puerto Rican)
    CL Item
    Yes_cuban2006639 (Yes, Cuban)
    CL Item
    Yes_central_american2006640 (Yes, Central American)
    CL Item
    Yes_south_american2006641 (Yes, South American)
    CL Item
    Yes_other2006642 (Yes, Other)
    CL Item
    Yes_nos2006643 (Yes, NOS)
    Item
    Patient's Race (select all that apply)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    Code List
    Patient's Race (select all that apply)
    CL Item
    White_cdus (White or Caucasian)
    CL Item
    Black_cdus (Black or African American)
    CL Item
    Pacific_islander_cdus (Native Hawaiian or Other Pacific Islander)
    CL Item
    Asian_cdus (Asian)
    CL Item
    Native_american_cdus (American Indian or Alaska Native)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Other, Specify (Other, Specify)
    Other,specify(patient'srace)
    Item
    Other, specify (patient's race) (If a U.S. resident)
    text
    PatientSocialSecurityNumber
    Item
    Patient's Social Security Number
    float
    PatientAddress,PostalCode
    Item
    Patient's Zip Code
    float
    PatientAddress,Country
    Item
    Country of Residence, if not USA (If a resident of Canada)
    text
    PatientSocialInsuranceIdentifierNumber
    Item
    Social Insurance Number
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C62650 (NCI Thesaurus ObjectClass-2)
    C0728831 (UMLS 2011AA ObjectClass-2)
    C16745 (NCI Thesaurus ObjectClass-3)
    C0021672 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    AddressPostalCode
    Item
    Postal Code (Statification Factors)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25407 (NCI Thesaurus ObjectClass)
    C1442065 (UMLS 2011AA ObjectClass)
    C25621 (NCI Thesaurus Property)
    C1514254 (UMLS 2011AA Property)
    Item
    Stage
    text
    Code List
    Stage
    CL Item
    Iiib (not Recurrent) (IIIB)
    CL Item
    Iv (not Recurrent) (IV)
    Item
    LDH
    text
    Code List
    LDH
    CL Item
    </= Uln (</= ULN)
    CL Item
    > Uln (> ULN)
    Item Group
    Notes
    Comments
    Item
    Notes
    text
    Item Group
    Ccrr Module For Southwest Oncology Group Registration Form

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