ID

43152

Beschrijving

S0201 Southwest Oncology Group Registration Form 2055861v3.0 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8B98C1F-D2E5-127C-E034-0003BA12F5E7 2055861v3.0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8B98C1F-D2E5-127C-E034-0003BA12F5E7

Trefwoorden

Versies (4)
  1. 18-12-14 18-12-14 - Martin Dugas
  2. 02-06-15 02-06-15 -
  3. 03-06-15 03-06-15 -
  4. 20-09-21 20-09-21 -
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20 september 2021

DOI

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Creative Commons BY-NC 3.0 Legacy
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S0201 Southwest Oncology Group Registration Form 2055861v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0201 Southwest Oncology Group Registration Form
    1. No Instruction available.
SWOG clinical trial administrative data
Beschrijving

SWOG clinical trial administrative data

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Assigned Treatment Arm
Beschrijving

TreatmentArmNumber

Datatype

text

Activation Date
Beschrijving

ActivationDate

Datatype

date

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
Beschrijving

DataAmendedLastDate

Datatype

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
Patient's Name
Beschrijving

PatientName

Datatype

text

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

Other Group Patient Number
Beschrijving

OtherGroupPatientIdentifierNumber

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ObjectClass-2
C16960
UMLS 2011AA ObjectClass-2
C0030705
NCI Thesaurus ObjectClass-3
C43359
UMLS 2011AA ObjectClass-3
C0441833
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Other Group Name/Protocol Number
Beschrijving

ParticipatingGroupName

Datatype

text

Registration data
Beschrijving

Registration data

Caller's SWOG Roster ID
Beschrijving

RegistrarSouthwestOncologyGroupIdentifierNumber

Datatype

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
IRB Approval Date
Beschrijving

IRBApprovalDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25425
UMLS 2011AA Property
C0205540
Projected Start Date of Treatment
Beschrijving

ProjectedTreatmentBeginDate

Datatype

date

Date Informed Consent Signed
Beschrijving

InformedConsentDateSigned

Datatype

date

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

SWOGInvestigatorNumber

Datatype

text

Other Group Investigator Name
Beschrijving

InvestigatorName

Datatype

text

Other Group Investigator Number
Beschrijving

OtherGroupInvestigatorNumber

Datatype

text

SWOG Treating Institution Number
Beschrijving

SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

Datatype

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
Other Group Institution Name
Beschrijving

InstitutionName

Datatype

text

Other Group Institution Number (Patient Consent for Specimen Use)
Beschrijving

NCIInstitutionNumber

Datatype

text

Patient's inital consent given for specimen use for research on the patient's cancer
Beschrijving

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datatype

boolean

Patient's initial consent given for specimen use for research unrelated to the patient's cancer
Beschrijving

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datatype

boolean

Patient's inital consent given for further contact regarding specimen
Beschrijving

PatientInitialConsent,Specimen,ContactInd

Datatype

boolean

Patient demographics
Beschrijving

Patient demographics

Patient's Date of Birth
Beschrijving

PatientBirthDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Gender
Beschrijving

PatientGender

Datatype

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
Beschrijving

PaymentMethod

Datatype

text

Patient's Ethnicity
Beschrijving

Patient'sEthnicity

Datatype

text

Patient's Race (select all that apply)
Beschrijving

PatientRace

Datatype

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)
Beschrijving

Other,specify(patient'srace)

Datatype

text

Patient's Social Security Number
Beschrijving

PatientSocialSecurityNumber

Datatype

float

Patient's Zip Code
Beschrijving

PatientAddress,PostalCode

Datatype

float

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

PatientAddress,Country

Datatype

text

Social Insurance Number
Beschrijving

PatientSocialInsuranceIdentifierNumber

Datatype

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)
Beschrijving

AddressPostalCode

Datatype

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
SLN biopsy
Beschrijving

SentinelNodeBiopsyInd

Datatype

boolean

HLA expression
Beschrijving

HLAType

Datatype

text

Stage of disease
Beschrijving

MalignantNeoplasmStageGroupingStage

Datatype

text

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ValueDomain
C16899
UMLS 2011AA ValueDomain
C1300072
NCI Thesaurus Property
C38027
UMLS 2011AA Property
C1519504
Ccrr Module For S0201 Southwest Oncology Group Registration Form
Beschrijving

Ccrr Module For S0201 Southwest Oncology Group Registration Form

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: S0201 Southwest Oncology Group Registration Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
date
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)
PatientName
Item
Patient's Name
text
SWOGPatientID
Item
SWOG Patient ID
text
OtherGroupPatientIdentifierNumber
Item
Other Group Patient Number
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass-2)
C0030705 (UMLS 2011AA ObjectClass-2)
C43359 (NCI Thesaurus ObjectClass-3)
C0441833 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
ParticipatingGroupName
Item
Other Group Name/Protocol Number
text
Item Group
Registration data
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)
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
date
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SWOGInvestigatorNumber
Item
SWOG Investigator Number
text
InvestigatorName
Item
Other Group Investigator Name
text
OtherGroupInvestigatorNumber
Item
Other Group Investigator Number
text
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)
InstitutionName
Item
Other Group Institution Name
text
NCIInstitutionNumber
Item
Other Group Institution Number (Patient Consent for Specimen Use)
text
PatientInitialConsent,Specimen,Patient'scancerresearchInd
Item
Patient's inital consent given for specimen use for research on the patient's cancer
boolean
PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
Item
Patient's initial consent given for specimen use for research unrelated to the patient's cancer
boolean
PatientInitialConsent,Specimen,ContactInd
Item
Patient's inital consent given for further contact regarding specimen
boolean
Item Group
Patient demographics
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
Gender
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)
CL.10
Code List
Gender
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
CL.5
Code List
Method of Payment
CL Item
Private Insurance (Private)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare and Private)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Self Pay (no Insurance) (No insurance (self-pay))
CL Item
No Means Of Payment (no Insurance) (No insurance (no means))
CL Item
Other (Other, specify at registration)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Sponsored (Veterans Admin)
CL Item
Military Sponsored (including Champus & Tricare) (Military)
Item
Patient's Ethnicity
text
CL.6
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)
CL.7
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)
SentinelNodeBiopsyInd
Item
SLN biopsy
boolean
Item
HLA expression
text
CL.9
Code List
HLA expression
CL Item
A2+ Only (A2+ only)
CL Item
C3+ Only (C3+ only)
CL Item
Both A2+ And C3+ (both A2+ and C3+)
Item
Stage of disease
text
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C38027 (NCI Thesaurus Property)
C1519504 (UMLS 2011AA Property)
CL.11
Code List
Stage of disease
CL Item
Iia (IIA)
CL Item
Iib (IIB)
CL Item
Iic/iiia (IIC/IIIA)
Item Group
Ccrr Module For S0201 Southwest Oncology Group Registration Form
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