ID

43239

Description

E3F05 Registration Worksheet (step 1) Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=612A5FBA-FC8E-B3D3-E040-BB89AD437EF0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=612A5FBA-FC8E-B3D3-E040-BB89AD437EF0

Keywords

Versions (4)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 8/4/15 8/4/15 - Martin Dugas
  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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Registration Glioma E3F05 NCT00978458

English

No Instruction available.

1 forms  
  1. StudyEvent: E3F05 Registration Worksheet (step 1)
    1. No Instruction available.
Eligibility
Description

Eligibility

First initial
Description

PatientFirstInitialsName

Data type

text

Last initial
Description

PatientLastInitialsName

Data type

text

Has the eligibility checklist been completed
Description

EligibilityDeterminationChecklistCompleteEligibilityInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C25171
UMLS 2011AA ObjectClass
C0013893
NCI Thesaurus Property-2
C49073
UMLS 2011AA Property-2
C1707357
In the opinion of the investigator, is the patient eligible?
Description

Eligibility for trial

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1302261
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25171
Age
Description

Age

Data type

integer

Measurement units
  • years
Alias
UMLS CUI [1]
C0001779
years
Karnofsky Performance Status
Description

Karnofsky Performance Status

Data type

integer

Measurement units
  • %
Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C20641
NCI Thesaurus ValueDomain
C25338
UMLS CUI [1]
C0206065
Patient's ECOG sequence number
Description

PersonEasternCooperativeOncologyGroupSequenceDeidentificationNumber

Data type

text

QOL contact person
Description

QualityofLifeContactPersonIdentifierName

Data type

text

Phone
Description

QualityofLifeContactPersonTelephoneNumber

Data type

text

Email address
Description

QualityofLifeContactPersonE-mailAddressText

Data type

text

Name of the institution that will administered the radiation therapy
Description

InstitutionRadiationTherapyAdministrationName

Data type

text

Patient Demographics / Pre-treatment Characteristics
Description

Patient Demographics / Pre-treatment Characteristics

Gender
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
Patient Birth Date
Description

Patient Birth Date

Data type

date

Measurement units
  • mm/yy
Alias
UMLS CUI [1]
C0421451
mm/yy
ZIP Code
Description

AddressPostalCodeIdentifier

Data type

text

Race (check all that apply)
Description

PatientRaceCategory

Data type

text

Patient Ethnicity
Description

PatientEthnicGroupCategory

Data type

text

Patient Hospital No.
Description

PatientMedicalRecordNumber

Data type

text

SSN
Description

SSN

Data type

text

Alias
UMLS CUI [1]
C1301821
Method of payment (check one)
Description

PatientInternationalPaymentType

Data type

text

Attending Physician
Description

AttendingPhysicianIdentifierIndividualsName

Data type

text

Institution contact
Description

InstitutionContactPersonName

Data type

text

Registrar
Description

ProtocolRegistrarName

Data type

text

Country of Residence (if not USA)
Description

PatientAddressCountryCode

Data type

text

Comments
Description

ResearchCommentsText

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E3F05 Registration Worksheet (step 1)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Eligibility
PatientFirstInitialsName
Item
First initial
text
PatientLastInitialsName
Item
Last initial
text
EligibilityDeterminationChecklistCompleteEligibilityInd-2
Item
Has the eligibility checklist been completed
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C49073 (NCI Thesaurus Property-2)
C1707357 (UMLS 2011AA Property-2)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Item
Karnofsky Performance Status
integer
C25367 (NCI Thesaurus Property)
C20641 (NCI Thesaurus ObjectClass)
C25338 (NCI Thesaurus ValueDomain)
C0206065 (UMLS CUI [1])
CL.3
Code List
Karnofsky Performance Status
CL Item
Normal, No Complaints, No Evidence Of Disease (100)
CL Item
Requires Occasional Assistance, But Is Able To Care For Most Of His/her Needs (60)
CL Item
Cares For Self, Unable To Carry On Normal Activity Or To Do Active Work (70)
CL Item
Normal Activity With Effort; Some Signs Or Symptoms Of Disease (80)
CL Item
Able To Carry On Normal Activity; Minor Signs Or Symptoms Of Disease (90)
CL Item
Dead (0)
CL Item
Moribund, Fatal Processes Progressing Rapidly (10)
CL Item
Very Sick, Hospitalization Indicated. Death Not Imminent (20)
CL Item
Severely Disabled, Hospitalization Indicated. Death Not Imminent (30)
CL Item
Disabled, Requires Special Care And Assistance (40)
CL Item
Requires Considerable Assistance And Frequent Medical Care (50)
PersonEasternCooperativeOncologyGroupSequenceDeidentificationNumber
Item
Patient's ECOG sequence number
text
QualityofLifeContactPersonIdentifierName
Item
QOL contact person
text
QualityofLifeContactPersonTelephoneNumber
Item
Phone
text
QualityofLifeContactPersonE-mailAddressText
Item
Email address
text
InstitutionRadiationTherapyAdministrationName
Item
Name of the institution that will administered the radiation therapy
text
Item Group
Patient Demographics / Pre-treatment Characteristics
Item
Gender
text
C0079399 (UMLS CUI [1])
CL.5
Code List
Gender
CL Item
Male (M)
C0086582 (UMLS CUI-1)
CL Item
Female (F)
C0086287 (UMLS CUI-1)
Birth Date
Item
Patient Birth Date
date
C0421451 (UMLS CUI [1])
AddressPostalCodeIdentifier
Item
ZIP Code
text
Item
Race (check all that apply)
text
CL.4
Code List
Race (check all that apply)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
CL Item
A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
CL Item
Not Provided Or Available (Not Reported)
CL Item
Could Not Be Determined Or Unsure (Unknown)
Item
Patient Ethnicity
text
CL.6
Code List
Patient Ethnicity
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
CL Item
Not Provided Or Available (Not reported)
CL Item
Could Not Be Determined Or Unsure (Unknown)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
Social security number
Item
SSN
text
C1301821 (UMLS CUI [1])
Item
Method of payment (check one)
text
CL.7
Code List
Method of payment (check one)
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare (Medicare)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Military Or Veterans Sponsored Nos (Military or Veterans Sponsored, Not Otherwise Specified (NOS))
CL Item
Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
CL Item
Veterans Sponsored (Veterans Sponsored)
CL Item
Self Pay (no Insurance) (Self Pay (No Insurance))
CL Item
No Means Of Payment (no Insurance) (No means of payment (no insurance))
CL Item
Other (Other)
CL Item
Unknown (Unknown)
AttendingPhysicianIdentifierIndividualsName
Item
Attending Physician
text
InstitutionContactPersonName
Item
Institution contact
text
ProtocolRegistrarName
Item
Registrar
text
Item
Country of Residence (if not USA)
text
CL.8
Code List
Country of Residence (if not USA)
CL Item
Ascension Island (AC)
CL Item
Andorra (AD)
CL Item
United Arab Emirates (AE)
CL Item
Afghanistan (AF)
CL Item
Antigua And Barbuda (AG)
CL Item
Anguilla (AI)
CL Item
Albania (AL)
CL Item
Armenia (AM)
CL Item
Netherland Antilles (AN)
CL Item
Angola (AO)
CL Item
Antarctica (AQ)
CL Item
Argentina (AR)
CL Item
American Samoa (AS)
CL Item
Austria (AT)
CL Item
Australia (AU)
CL Item
Aruba (AW)
CL Item
Azerbaidjan (AZ)
CL Item
Bosnia-herzegovina (BA)
CL Item
Barbados (BB)
CL Item
Bangladesh (BD)
CL Item
Belgium (BE)
CL Item
Burkina Faso (BF)
CL Item
Bulgaria (BG)
CL Item
Bahrain (BH)
CL Item
Burundi (BI)
CL Item
Benin (BJ)
CL Item
Bermuda (BM)
CL Item
Brunei Darussalam (BN)
CL Item
Bolivia (BO)
CL Item
Brazil (BR)
CL Item
Bahamas (BS)
CL Item
Bhutan (BT)
CL Item
Bouvet Island (BV)
CL Item
Botswana (BW)
CL Item
Belarus (BY)
CL Item
Belize (BZ)
CL Item
Canada (CA)
CL Item
Cocos Isl. (CC)
CL Item
Rep. Dem. Congo (CD)
CL Item
Central African Rep. (CF)
CL Item
Congo (CG)
CL Item
Switzerland (CH)
CL Item
Ivory Coast (CI)
CL Item
Cook Islands (CK)
CL Item
Chile (CL)
CL Item
Cameroon (CM)
CL Item
China (CN)
CL Item
Colombia (CO)
CL Item
Costa Rica (CR)
CL Item
Cuba (CU)
CL Item
Cape Verde (CV)
CL Item
Christmas Island (CX)
CL Item
Cyprus (CY)
CL Item
Czech Republic (CZ)
CL Item
Germany (DE)
CL Item
Djibouti (DJ)
CL Item
Denmark (DK)
CL Item
Dominica (DM)
CL Item
Dominican Republic (DO)
CL Item
Algeria (DZ)
CL Item
Ecuador (EC)
CL Item
Estonia (EE)
CL Item
Egypt (EG)
CL Item
Western Sahara (EH)
CL Item
Eritrea (ER)
CL Item
Spain (ES)
CL Item
Ethiopia (ET)
CL Item
Finland (FI)
CL Item
Fiji (FJ)
CL Item
Falkland Isl. (FK)
CL Item
Micronesia (FM)
CL Item
Faroe Islands (FO)
CL Item
France (FR)
CL Item
France (european Ter.) (FX)
CL Item
Gabon (GA)
CL Item
Great Britain (GB)
CL Item
Grenada (GD)
CL Item
Georgia (GE)
CL Item
Guiana (fr.) (GF)
CL Item
Guernsey (GG)
CL Item
Ghana (GH)
CL Item
Gibraltar (GI)
CL Item
Greenland (GL)
CL Item
Gambia (GM)
CL Item
Guinea (GN)
CL Item
Guadeloupe (fr.) (GP)
CL Item
Equatorial Guinea (GQ)
CL Item
Greece (GR)
CL Item
South Georgia And South Sandwich Islands (GS)
CL Item
Guatemala (GT)
CL Item
Guam (us) (GU)
CL Item
Guinea Bissau (GW)
CL Item
Guyana (GY)
CL Item
Hong Kong (HK)
CL Item
Heard & Mcdonald Isl. (HM)
CL Item
Honduras (HN)
CL Item
Croatia (HR)
CL Item
Haiti (HT)
CL Item
Hungary (HU)
CL Item
Indonesia (ID)
CL Item
Ireland (IE)
CL Item
Israel (IL)
CL Item
Isle Of Man (IM)
CL Item
India (IN)
CL Item
British Indian O. Ter. (IO)
CL Item
Iraq (IQ)
CL Item
Iran (IR)
CL Item
Iceland (IS)
CL Item
Italy (IT)
CL Item
Jersey (JE)
CL Item
Jamaica (JM)
CL Item
Jordan (JO)
CL Item
Japan (JP)
CL Item
Kenya (KE)
CL Item
Kyrgyz Republic (KG)
CL Item
Cambodia (KH)
CL Item
Kiribati (KI)
CL Item
Comoros (KM)
CL Item
St. Kitts Nevis Anguilla (KN)
CL Item
Korea (north) (KP)
CL Item
Korea (south) (KR)
CL Item
Kuwait (KW)
CL Item
Cayman Islands (KY)
CL Item
Kazakstan (KZ)
CL Item
Laos (LA)
CL Item
Lebanon (LB)
CL Item
Saint Lucia (LC)
CL Item
Liechtenstein (LI)
CL Item
Sri Lanka (LK)
CL Item
Liberia (LR)
CL Item
Lesotho (LS)
CL Item
Lithuania (LT)
CL Item
Luxembourg (LU)
CL Item
Latvia (LV)
CL Item
Libya (LY)
CL Item
Morocco (MA)
CL Item
Monaco (MC)
CL Item
Moldova (MD)
CL Item
Madagascar (MG)
CL Item
Marshall Islands (MH)
CL Item
Macedonia (MK)
CL Item
Mali (ML)
CL Item
Myanmar (MM)
CL Item
Mongolia (MN)
CL Item
Macau (MO)
CL Item
Northern Mariana Isl. (MP)
CL Item
Martinique (fr.) (MQ)
CL Item
Mauritania (MR)
CL Item
Montserrat (MS)
CL Item
Malta (MT)
CL Item
Mauritius (MU)
CL Item
Maldives (MV)
CL Item
Malawi (MW)
CL Item
Mexico (MX)
CL Item
Malaysia (MY)
CL Item
Mozambique (MZ)
CL Item
Namibia (NA)
CL Item
New Caledonia (fr.) (NC)
CL Item
Niger (NE)
CL Item
Norfolk Island (NF)
CL Item
Nigeria (NG)
CL Item
Nicaragua (NI)
CL Item
Netherlands (NL)
CL Item
Norway (NO)
CL Item
Nepal (NP)
CL Item
Nauru (NR)
CL Item
Niue (NU)
CL Item
New Zealand (NZ)
CL Item
Oman (OM)
CL Item
Other (Other)
CL Item
Panama (PA)
CL Item
Peru (PE)
CL Item
Polynesia (fr.) (PF)
CL Item
Papua New Guinea (PG)
CL Item
Philippines (PH)
CL Item
Pakistan (PK)
CL Item
Poland (PL)
CL Item
St. Pierre & Miquelon (PM)
CL Item
Pitcairn (PN)
CL Item
Puerto Rico (PR)
CL Item
Portugal (PT)
CL Item
Palau (PW)
CL Item
Paraguay (PY)
CL Item
Qatar (QA)
CL Item
Reunion (fr.) (RE)
CL Item
Romania (RO)
CL Item
Russian Federation (RU)
CL Item
Rwanda (RW)
CL Item
Saudi Arabia (SA)
CL Item
Solomon Islands (SB)
CL Item
Seychelles (SC)
CL Item
Sudan (SD)
CL Item
Sweden (SE)
CL Item
Singapore (SG)
CL Item
St. Helena (SH)
CL Item
Slovenia (SI)
CL Item
Svalbard & Jan Mayen Isl. (SJ)
CL Item
Slovakia (SK)
CL Item
Sierra Leone (SL)
CL Item
San Marino (SM)
CL Item
Senegal (SN)
CL Item
Somalia (SO)
CL Item
Suriname (SR)
CL Item
St. Tome And Principe (ST)
CL Item
Soviet Union (SU)
CL Item
El Salvador (SV)
CL Item
Syria (SY)
CL Item
Swaziland (SZ)
CL Item
Turks & Caicos Islands (TC)
CL Item
Chad (TD)
CL Item
French Southern Terr. (TF)
CL Item
Togo (TG)
CL Item
Thailand (TH)
CL Item
Tadjikistan (TJ)
CL Item
Tokelau (TK)
CL Item
Turkmenistan (TM)
CL Item
Tunisia (TN)
CL Item
Tonga (TO)
CL Item
East Timor (TP)
CL Item
Turkey (TR)
CL Item
Trinidad & Tobago (TT)
CL Item
Tuvalu (TV)
CL Item
Taiwan (TW)
CL Item
Tanzania (TZ)
CL Item
Ukraine (UA)
CL Item
Uganda (UG)
CL Item
United Kingdom (UK)
CL Item
Us Minor Outlying Isl. (UM)
CL Item
Usa (US)
CL Item
Uruguay (UY)
CL Item
Uzbekistan (UZ)
CL Item
Vatican City State (VA)
CL Item
St. Vincent & Grenadines (VC)
CL Item
Venezuela (VE)
CL Item
Virgin Islands (brit) (VG)
CL Item
Virgin Islands (us) (VI)
CL Item
Vietnam (VN)
CL Item
Vanuatu (VU)
CL Item
Wallis & Futuna Islands (WF)
CL Item
Western Samoa (WS)
CL Item
Yemen (YE)
CL Item
Mayotte (YT)
CL Item
Yugoslavia (YU)
CL Item
South Africa (ZA)
CL Item
Zambia (ZM)
CL Item
Dem. Rep. Of Congo (ZR)
CL Item
Zimbabwe (ZW)
ResearchCommentsText
Item
Comments
text
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