ID

43331

Description

NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9BED937-4416-2507-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9BED937-4416-2507-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104)

English

No Instruction available.

1 forms  
  1. StudyEvent: NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104
    1. No Instruction available.
Mskcc 00-138; Calgb-90104; Ecog
Description

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Description

CoordinatingGroupProtocolNumber

Data type

text

Coordinating Group Code
Description

CoordinatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Data type

text

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Patient Medical Record Number
Description

PatientMedicalRecordNumber

Data type

text

Patient Study ID, Participating Group
Description

PatientStudyID,ParticipatingGroup

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Afiiliate
Description

AffiliateName

Data type

text

Physician of Record
Description

RegisteredInvestigator

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

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
Date Informed Consent Signed
Description

InformedConsentDateSigned

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Person Completing Form, Phone
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Person Completing Form, Fax
Description

PersonCompletingForm,Fax

Data type

float

Projected Start Date of Treatment
Description

ProjectedTreatmentBeginDate

Data type

date

Date of Registration
Description

RegistrationDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Patient Demographics / Pre-treatment Characteristics
Description

Patient Demographics / Pre-treatment Characteristics

Patient Name, Last (initials acceptable)
Description

PatientName,Last

Data type

text

Patient Name, First (initials acceptable)
Description

PatientName,First

Data type

text

Patient Name, Middle (initials acceptable)
Description

PatientName,Middle

Data type

text

Patient Birth Date (MM DD YYYY)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient Gender
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
Patient Race/Ethnicity (check one)
Description

PatientRace/Ethnicity

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Patient Social Security Number
Description

PatientSocialSecurityNumber

Data type

float

Street Address
Description

Address,Line1

Data type

text

City
Description

Address,City

Data type

text

State
Description

Address,StateCode

Data type

text

Patient?s ZIP Code (USA)
Description

PatientAddress,PostalCode

Data type

float

Country of Residence (if not USA)
Description

PatientAddress,Country

Data type

text

Patient Height (cm)
Description

PatientHeight

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25347
UMLS 2011AA Property
C0489786
Patient Weight (kg)
Description

PatientWeight

Data type

float

Body Surface Area
Description

BodySurfaceArea

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Performance Status (check one)
Description

PerformanceStatus

Data type

text

Certification Of Eligibility
Description

Certification Of Eligibility

In the opinion of the investigator is the patient eligible?
Description

PatientEligibilityInd

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25171
UMLS 2011AA Property
C0013893
Protocol Design
Description

Protocol Design

Primary Tumor Pathological Stage
Description

TStage,Pathologic

Data type

text

Number of Nodes Involved By Tumor (check one)
Description

NumberofNodesInvolvedByTumor

Data type

text

Initial Patient Consent For Specimen Use
Description

Initial Patient Consent For Specimen Use

Patient?s Initial Consent given for specimen use for research on the patient?s cancer?
Description

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Data type

boolean

Patient?s Initial Consent given for specien use for research unrelated to the patient?s cancer?
Description

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Data type

boolean

Patient?s Initial Consent given for further contact regarding specimen?
Description

PatientInitialConsent,Specimen,ContactInd

Data type

boolean

Date of Consent for Specimen Use (MM DD YYYY)
Description

InformedConsentDateSigned,SpecimenUse

Data type

date

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Mskcc 00-138; Calgb-90104; Ecog
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Afiiliate
text
RegisteredInvestigator
Item
Physician of Record
text
Item Group
Protocol Administration
IRB/REBApprovalDate
Item
IRB/REB Approval Date
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
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)
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PersonCompletingForm,Phone
Item
Person Completing Form, Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
PersonCompletingForm,Fax
Item
Person Completing Form, Fax
float
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
RegistrationDate
Item
Date of Registration
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Patient Demographics / Pre-treatment Characteristics
PatientName,Last
Item
Patient Name, Last (initials acceptable)
text
PatientName,First
Item
Patient Name, First (initials acceptable)
text
PatientName,Middle
Item
Patient Name, Middle (initials acceptable)
text
PatientBirthDate
Item
Patient Birth Date (MM DD YYYY)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
Patient 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.1
Code List
Patient Gender
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Item
Patient Race/Ethnicity (check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.2
Code List
Patient Race/Ethnicity (check one)
CL Item
White_cdus (White, not of Hispanic origin)
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race (Hispanic)
CL Item
Black_cdus (Black, not of Hispanic origin)
CL Item
Pacific_islander_cdus (Native Hawaiian or other Pacific Islander)
CL Item
Asian_cdus (Asian)
CL Item
Native_american_cdus (Native North American)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientSocialSecurityNumber
Item
Patient Social Security Number
float
Address,Line1
Item
Street Address
text
Address,City
Item
City
text
Address,StateCode
Item
State
text
PatientAddress,PostalCode
Item
Patient?s ZIP Code (USA)
float
PatientAddress,Country
Item
Country of Residence (if not USA)
text
PatientHeight
Item
Patient Height (cm)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
PatientWeight
Item
Patient Weight (kg)
float
BodySurfaceArea
Item
Body Surface Area
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item
Performance Status (check one)
text
CL.3
Code List
Performance Status (check one)
CL Item
0 (Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90 - 100))
C0919414 (NCI Metathesaurus)
CL Item
1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
CL Item
2 (Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50 - 60))
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (K 30 - 40))
CL Item
4 (Completely disabled (K 10 - 20))
Item Group
Certification Of Eligibility
PatientEligibilityInd
Item
In the opinion of the investigator is the patient eligible?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25171 (NCI Thesaurus Property)
C0013893 (UMLS 2011AA Property)
Item Group
Protocol Design
Item
Primary Tumor Pathological Stage
text
CL.5
Code List
Primary Tumor Pathological Stage
CL Item
Tumor Invades Subepithelial Connective Tissue (T1)
CL Item
Tumor Invades Superficial Muscles (inner Half) (T2)
CL Item
Tumor Invades Perivesical Tissue Microscopically (T3)
CL Item
Inflammatory Carcinoma (T4)
C0334385 (NCI Metathesaurus)
Item
Number of Nodes Involved By Tumor (check one)
text
CL.6
Code List
Number of Nodes Involved By Tumor (check one)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1/5/2002 (1/5/2002)
CL Item
>=6 (>=6)
CL Item
A (A)
C14653 (NCI Thesaurus)
CL Item
B (B)
Item Group
Initial Patient Consent For Specimen Use
PatientInitialConsent,Specimen,Patient'scancerresearchInd
Item
Patient?s Initial Consent given for specimen use for research on the patient?s cancer?
boolean
PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
Item
Patient?s Initial Consent given for specien use for research unrelated to the patient?s cancer?
boolean
PatientInitialConsent,Specimen,ContactInd
Item
Patient?s Initial Consent given for further contact regarding specimen?
boolean
InformedConsentDateSigned,SpecimenUse
Item
Date of Consent for Specimen Use (MM DD YYYY)
date
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