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ID

43130

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-05-28 2015-05-28 -
  3. 2021-09-20 2021-09-20 -
Uppladdad den

20 september 2021

DOI

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Licens

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
    Beskrivning

    SWOG clinical trial administrative data

    SWOG Study No.
    Beskrivning

    SWOGStudyNo.

    Datatyp

    text

    Registration Step
    Beskrivning

    RegistrationStep

    Datatyp

    text

    Assigned Treatment Arm
    Beskrivning

    TreatmentArmNumber

    Datatyp

    text

    Activation Date
    Beskrivning

    ActivationDate

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C64382 (undefined)
    UMLS 2011AA Property
    C1879547 (Activation action)
    LOINC
    LA29299-7
    NCI Thesaurus Property-2
    C41200 (undefined)
    UMLS 2011AA Property-2
    C0680532 (Amendment)
    Last Amended Date
    Beskrivning

    DataAmendedLastDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C25416 (undefined)
    UMLS 2011AA Property
    C1691222 (Amended)
    NCI Thesaurus ValueDomain-2
    C25551 (undefined)
    UMLS 2011AA ValueDomain-2
    C1517741 (Last)
    LOINC
    LP200101-6
    Caller's SWOG Roster ID
    Beskrivning

    RegistrarSouthwestOncologyGroupIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property-2
    C25699 (undefined)
    UMLS 2011AA Property-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass
    C25357 (undefined)
    UMLS 2011AA ObjectClass
    C0557514 (Registrar)
    SNOMED
    224531000
    LOINC
    LA4379-9
    SWOG Treating Institution Number
    Beskrivning

    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C25699 (undefined)
    UMLS 2011AA ObjectClass
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass-2
    C25705 (undefined)
    UMLS 2011AA ObjectClass-2
    C1522326 (Treating)
    NCI Thesaurus ObjectClass-3
    C41206 (undefined)
    UMLS 2011AA ObjectClass-3
    C1272753 (Institution (social concept))
    SNOMED
    385437003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    Date Informed Consent Signed
    Beskrivning

    InformedConsentDateSigned

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    SWOG Investigator Number
    Beskrivning

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25699 (undefined)
    UMLS 2011AA ObjectClass
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass-2
    C17089 (undefined)
    UMLS 2011AA ObjectClass-2
    C0035173 (Research Personnel)
    SNOMED
    769038007
    LOINC
    LA23773-7
    IRB Approval Date
    Beskrivning

    IRBApprovalDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C25425 (undefined)
    UMLS 2011AA Property
    C0205540 (Approved)
    SNOMED
    9571008
    Projected Start Date of Treatment (Patient Consent for Specimen Use)
    Beskrivning

    ProjectedTreatmentBeginDate

    Datatyp

    date

    patient demographics
    Beskrivning

    patient demographics

    Patient's Name
    Beskrivning

    Patient'sName

    Datatyp

    text

    SWOG Patient ID
    Beskrivning

    SWOGPatientID

    Datatyp

    text

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

    PatientInitialConsent,Specimen,Patient'scancerresearchInd

    Datatyp

    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)
    Beskrivning

    PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

    Datatyp

    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
    Beskrivning

    PatientInitialConsent,Specimen,ContactInd

    Datatyp

    boolean

    Patient's Date of Birth
    Beskrivning

    PatientBirthDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25275 (undefined)
    UMLS 2011AA Property
    C2745955 (Occurrence)
    SNOMED
    246454002
    Patient's Sex
    Beskrivning

    PatientGender

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372 (undefined)
    UMLS 2011AA ValueDomain
    C0683312 (Categories)
    LOINC
    MTHU018876
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C17357 (undefined)
    UMLS 2011AA Property
    C0079399 (Gender)
    SNOMED
    263495000
    LOINC
    LP61312-2
    Method of Payment
    Beskrivning

    PaymentMethod

    Datatyp

    text

    Patient's Ethnicity
    Beskrivning

    Patient'sEthnicity

    Datatyp

    text

    Patient's Race (select all that apply)
    Beskrivning

    PatientRace

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C17049 (undefined)
    UMLS 2011AA Property
    C0034510 (Racial group)
    SNOMED
    415229000
    LOINC
    LP7528-5
    Other, specify (patient's race) (If a U.S. resident)
    Beskrivning

    Other,specify(patient'srace)

    Datatyp

    text

    Patient's Social Security Number
    Beskrivning

    PatientSocialSecurityNumber

    Datatyp

    float

    Patient's Zip Code
    Beskrivning

    PatientAddress,PostalCode

    Datatyp

    float

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

    PatientAddress,Country

    Datatyp

    text

    Social Insurance Number
    Beskrivning

    PatientSocialInsuranceIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ObjectClass-2
    C62650 (undefined)
    UMLS 2011AA ObjectClass-2
    C0728831 (Social)
    NCI Thesaurus ObjectClass-3
    C16745 (undefined)
    UMLS 2011AA ObjectClass-3
    C0021672 (Insurance)
    LOINC
    LA21462-9
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    Postal Code (Statification Factors)
    Beskrivning

    AddressPostalCode

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    NCI Thesaurus ObjectClass
    C25407 (undefined)
    UMLS 2011AA ObjectClass
    C1442065 (Address)
    SNOMED
    397635003
    LOINC
    LP96251-1
    NCI Thesaurus Property
    C25621 (undefined)
    UMLS 2011AA Property
    C1514254 (Postal Code)
    Stage
    Beskrivning

    StageGrouping

    Datatyp

    text

    LDH
    Beskrivning

    LDH

    Datatyp

    text

    Notes
    Beskrivning

    Notes

    Notes
    Beskrivning

    Comments

    Datatyp

    text

    Ccrr Module For Southwest Oncology Group Registration Form
    Beskrivning

    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
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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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