ID

43195

Description

CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION NCT00016276 Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8542-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8542-227A-E034-080020C9C0E0

Keywords

Versions (4)
  1. 8/26/12 8/26/12 -
  2. 5/22/15 5/22/15 -
  3. 6/3/15 6/3/15 -
  4. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

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License

Creative Commons BY-NC 3.0 Legacy
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CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION NCT00016276

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
    1. No Instruction available.
CALGB Information
Description

CALGB Information

CALGB Patient Number
Description

CALGBPatientNumber

Data type

text

Participating Group Code Patient No.
Description

ParticipatingGroupCodePatientNo.

Data type

text

Patient Medical Record No.
Description

PatientMedicalRecordNo.

Data type

text

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Main Member Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician of Record
Description

RegisteredInvestigator

Data type

text

FAX
Description

FAX

Data type

text

Phone
Description

Phone

Data type

text

Protocol Administration
Description

Protocol Administration

IRB/REB Approval Date
Description

IRB/REBApprovalDate

Data type

text

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

Consent Form Date
Description

ConsentFormDate

Data type

text

Person Completing Form, first Name
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Projected Start Date
Description

ProjectedStartDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
NCI Thesaurus ValueDomain
C25631
Person Phone
Description

PersonPhone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
Person Fax
Description

PersonFax

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25210
UMLS 2011AA Property
C0085205
Date of Registration
Description

RegistrationDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Registrar
Description

Registrar

Data type

text

Patient Demographics / Pre U Treatment Characteristics
Description

Patient Demographics / Pre U Treatment Characteristics

Patient Name (l,f,m.i.)
Description

PatientName

Data type

text

Social Security Number (USA Only)
Description

PatientSocialSecurityNumber

Data type

double

Patient Race/ Ethnicity
Description

PatientRace/Ethnicity

Data type

text

Sex
Description

Sex

Data type

text

Birthdate
Description

Birthdate

Data type

text

Method of Payment
Description

MethodofPayment

Data type

text

Zip Code
Description

ZipCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Performance Status
Description

PerformanceStatus

Data type

text

Pt Height (cm)
Description

PtHeight

Data type

text

Pt Weight (kg)
Description

PtWeight

Data type

text

BSA (m2)
Description

BSA

Data type

text

Patient Eligible?
Description

PatientEligible?

Data type

text

Name of medical oncologist
Description

Nameofmedicaloncologist

Data type

text

Name of RT oncologist
Description

NameofRToncologist

Data type

text

RN Coordinator
Description

RNCoordinator

Data type

text

Surgeon
Description

Surgeon

Data type

text

Stratification Factors
Description

Stratification Factors

Disease Type
Description

DiseaseType

Data type

text

ASSIGNED TREATMENT ARM
Description

ProtocolTreatmentArmAssignmentText

Data type

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C32141
UMLS 2011AA Property
C1140618
NCI Thesaurus Property
C25426
UMLS 2011AA Property
C1516050
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Patient?s initial consent given for specimen use for research on the patient?s cancer?
Description

Patient?sinitialconsentgivenforspecimenuseforresearchonthepatient?scancer?

Data type

text

Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
Description

Patient?sinitialconsentgivenforspecimenuseforresearchunrelatedtothepatient?scancer?

Data type

text

Patient?s initial consent given for further contact regarding specimen?
Description

Patient'sinitialconsentgivenforfurthercontactregardingspecimen?

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB COOPERATIVE GROUP ADJUVANT BREAST CANCER RANDOMIZATION
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB Information
CALGBPatientNumber
Item
CALGB Patient Number
text
ParticipatingGroupCodePatientNo.
Item
Participating Group Code Patient No.
text
PatientMedicalRecordNo.
Item
Patient Medical Record No.
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
MainMemberInstitution/Affiliate
Item
Main Member Institution/Affiliate
text
RegisteredInvestigator
Item
Physician of Record
text
FAX
Item
FAX
text
Phone
Item
Phone
text
Item Group
Protocol Administration
IRB/REBApprovalDate
Item
IRB/REB Approval Date
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
ConsentFormDate
Item
Consent Form Date
text
PersonCompletingForm,FirstName
Item
Person Completing Form, first Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProjectedStartDate
Item
Projected Start Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C25631 (NCI Thesaurus ValueDomain)
PersonPhone
Item
Person Phone
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
PersonFax
Item
Person Fax
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
RegistrationDate
Item
Date of Registration
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Registrar
Item
Registrar
text
Item Group
Patient Demographics / Pre U Treatment Characteristics
PatientName
Item
Patient Name (l,f,m.i.)
text
PatientSocialSecurityNumber
Item
Social Security Number (USA Only)
double
Item
Patient Race/ Ethnicity
text
CL.1
Code List
Patient Race/ Ethnicity
CL Item
White (White)
CL Item
Hispanic (Hispanic)
CL Item
Black (Black)
CL Item
Oriental (Oriental)
CL Item
Native Hawaiian (Native Hawaiian)
CL Item
Native American (Native American)
CL Item
Indian (Indian)
CL Item
Filipino (Filipino)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Patient Refusal (Patient refusal)
CL Item
Institution Refusal (Institution refusal)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Sex
text
CL.2
Code List
Sex
CL Item
Male (M)
C20197 (NCI Thesaurus)
C0086582 (UMLS 2011AA)
CL Item
Female (F)
C16576 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Birthdate
Item
Birthdate
text
Item
Method of Payment
text
CL.3
Code List
Method of Payment
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Millitary Or Veterans Administration (Millitary or Veterans Administration)
CL Item
Self Pay (Self Pay)
CL Item
No Means Of Payment (No means of payment)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Zip Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
CL.4
Code List
Zip Code
CL Item
(usa Only) ((USA Only))
Item
Performance Status
text
CL.5
Code List
Performance Status
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction, (Fully active, able to carry on all pre-disease performance without restriction,)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory, (Restricted in physically strenuous activity but ambulatory,)
CL Item
Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities, (Ambulatory and capable of all selfcare but unable to carry out any work activities,)
CL Item
Capable Of Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours, (Capable of limited selfcare, confined to bed or chair more than 50% of waking hours,)
CL Item
Completely Disabled (Completely disabled)
PtHeight
Item
Pt Height (cm)
text
PtWeight
Item
Pt Weight (kg)
text
BSA
Item
BSA (m2)
text
Item
Patient Eligible?
text
CL.6
Code List
Patient Eligible?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, All Requirements Confirmed (Yes, all requirements confirmed)
Nameofmedicaloncologist
Item
Name of medical oncologist
text
NameofRToncologist
Item
Name of RT oncologist
text
RNCoordinator
Item
RN Coordinator
text
Surgeon
Item
Surgeon
text
Item Group
Stratification Factors
Item
Disease Type
text
CL.7
Code List
Disease Type
CL Item
Inflammatory (Inflammatory)
C25535 (NCI Thesaurus)
C0333348 (UMLS 2011AA)
CL Item
Noninflammatory, Inoperable Stage Iii/regional Stage Iv (Noninflammatory, inoperable Stage III/regional Stage IV)
CL Item
Operable Stage Iii (Operable Stage III)
ProtocolTreatmentArmAssignmentText
Item
ASSIGNED TREATMENT ARM
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C32141 (NCI Thesaurus Property)
C1140618 (UMLS 2011AA Property)
C25426 (NCI Thesaurus Property)
C1516050 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Patient?s initial consent given for specimen use for research on the patient?s cancer?
text
CL.8
Code List
Patient?s initial consent given for specimen use for research on the patient?s cancer?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
text
CL.9
Code List
Patient?s initial consent given for specimen use for research unrelated to the patient?s cancer?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Patient?s initial consent given for further contact regarding specimen?
text
CL.10
Code List
Patient?s initial consent given for further contact regarding specimen?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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