ID

4737

Descrição

NCCTG N0733 Demography Form Capecitabine and Lapatinib With or Without Cixutumumab in Treating Patients With Previously Treated HER2-Positive Stage IIIB, Stage IIIC, or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=643B1D4E-2802-CA4C-E040-BB89AD432C8F

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=643B1D4E-2802-CA4C-E040-BB89AD432C8F

Palavras-chave

Versões (4)
  1. 27/08/2012 27/08/2012 -
  2. 24/03/2014 24/03/2014 - Martin Dugas
  3. 24/03/2014 24/03/2014 - Martin Dugas
  4. 17/09/2021 17/09/2021 -
Transferido a

24 de março de 2014

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00684983 Demographic - NCCTG N0733 Demography Form - 2842806v1.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: NCCTG N0733 Demography Form
    1. No Instruction available.
Standard Patient Identifier
Descrição

Standard Patient Identifier

Last
Descrição

PatientLastInitialsName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C25551
UMLS 2011AA Property
C1517741
First
Descrição

PatientFirstInitialsName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
Middle
Descrição

PatientMiddleInitialsName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C25569
UMLS 2011AA Property
C0444598
Patient SSN
Descrição

PatientSSNNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25686
UMLS 2011AA Property
C1301821
Patient Hospital No.
Descrição

PatientMedicalRecordNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25261
UMLS 2011AA Property
C0205476
NCI Thesaurus Property
C25198
UMLS 2011AA Property
C0034869
Standard Demographics
Descrição

Standard Demographics

Alias
UMLS CUI-1
C1704791
Ethnicity
Descrição

Ethnicity

Tipo de dados

text

Alias
NCI Thesaurus Property
C25372
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C16564
UMLS CUI-1
C0015031
Gender of a Person
Descrição

Gender

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C17357
UMLS CUI-1
C0079399
Patient's Date of Birth
Descrição

Birth Date

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C25155
UMLS CUI-1
C0421451
2000 Census Tract Codes
Descrição

Census Tract Codes

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16495
NCI Thesaurus Property
C67490
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain
C25407
NCI Thesaurus ValueDomain
C67490
Patient's Country of Residence
Descrição

Country

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25464
NCI Thesaurus Property
C25407
NCI Thesaurus ValueDomain
C42614
UMLS CUI-1
C1562954
Patient's ZIP Code
Descrição

Postal Code

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25407
NCI Thesaurus Property
C25621
NCI Thesaurus ValueDomain
C25364
NCI Thesaurus ValueDomain
C25407
NCI Thesaurus ValueDomain
C25621
UMLS CUI-1
C0421454
Race
Descrição

Race

Race
Descrição

RaceCategoryText

Tipo de dados

text

Alias
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C17049
UMLS 2011AA ObjectClass
C0034510
Method Of Payment
Descrição

Method Of Payment

Method of Payment
Descrição

PaymentMethod

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ObjectClass
C25371
UMLS 2011AA ObjectClass
C0680264
Optional Questions
Descrição

Optional Questions

CDC Race Code
Descrição

CentersforDiseaseControlandPreventionRaceUniqueIdentifierCode

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ObjectClass
C17049
UMLS 2011AA ObjectClass
C0034510
CDC Ethnicity Code
Descrição

CentersforDiseaseControlandPreventionEthnicityUniqueIdentifierCodes

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ObjectClass
C16564
UMLS 2011AA ObjectClass
C0015031
Education Level
Descrição

PersonEducationLevelType

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17953
UMLS 2011AA Property
C0013658
NCI Thesaurus ValueDomain
C17953
UMLS 2011AA ValueDomain
C0013658
Marital Status
Descrição

PersonMaritalStatusCategory

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus Property
C25188
UMLS 2011AA Property
C0024819
Place of Birth
Descrição

PersonGeographicBirthPlaceText

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25155
UMLS 2011AA Property
C0005615
NCI Thesaurus Property
C25319
UMLS 2011AA Property
C0442504
NCI Thesaurus Property
C37957
UMLS 2011AA Property
C1517526
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25155
UMLS 2011AA ValueDomain
C0005615
NCI Thesaurus ValueDomain
C25319
UMLS 2011AA ValueDomain
C0442504
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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: NCCTG N0733 Demography Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Standard Patient Identifier
PatientLastInitialsName
Item
Last
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C25551 (NCI Thesaurus Property)
C1517741 (UMLS 2011AA Property)
PatientFirstInitialsName
Item
First
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
PatientMiddleInitialsName
Item
Middle
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C25569 (NCI Thesaurus Property)
C0444598 (UMLS 2011AA Property)
PatientSSNNumber
Item
Patient SSN
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25686 (NCI Thesaurus Property)
C1301821 (UMLS 2011AA Property)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (UMLS 2011AA Property)
Item Group
Standard Demographics
C1704791 (UMLS CUI-1)
Item
Ethnicity
text
C25372 (NCI Thesaurus Property)
C25372 (NCI Thesaurus ValueDomain)
C16564 (NCI Thesaurus ObjectClass)
C0015031 (UMLS CUI-1)
CL.1
Code List
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)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Gender of a Person
text
C25284 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI-1)
CL.2
Code List
Gender of a Person
CL Item
Female Gender (Female Gender)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
CL Item
Male Gender (Male Gender)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Unspecified (Unspecified)
C38046 (NCI Thesaurus)
C0205370 (UMLS 2011AA)
Birth Date
Item
Patient's Date of Birth
date
C25164 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
Census Tract Codes
Item
2000 Census Tract Codes
text
C16495 (NCI Thesaurus ObjectClass)
C67490 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C25704 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C67490 (NCI Thesaurus ValueDomain)
Country
Item
Patient's Country of Residence
text
C16960 (NCI Thesaurus ObjectClass)
C25464 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus Property)
C42614 (NCI Thesaurus ValueDomain)
C1562954 (UMLS CUI-1)
Postal Code
Item
Patient's ZIP Code
text
C25407 (NCI Thesaurus ObjectClass)
C25621 (NCI Thesaurus Property)
C25364 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C25621 (NCI Thesaurus ValueDomain)
C0421454 (UMLS CUI-1)
Item Group
Race
Item
Race
text
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)
CL.3
Code List
Race
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)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
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)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
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)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
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)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Method Of Payment
Item
Method of Payment
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25371 (NCI Thesaurus ObjectClass)
C0680264 (UMLS 2011AA ObjectClass)
CL.4
Code List
Method of Payment
CL Item
Private Insurance (1)
CL Item
Medicare (2)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (3)
CL Item
Medicaid (4)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (5)
CL Item
Military Or Veterans Sponsored Nos (6)
CL Item
Military Sponsored (including Champus &tricare) (6a)
CL Item
Veterans Sponsored (6b)
CL Item
Self Pay (no Insurance) (7)
CL Item
No Means Of Payment (no Insurance) (8)
CL Item
Other (98)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (99)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Optional Questions
CentersforDiseaseControlandPreventionRaceUniqueIdentifierCode
Item
CDC Race Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)
CentersforDiseaseControlandPreventionEthnicityUniqueIdentifierCodes
Item
CDC Ethnicity Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C16564 (NCI Thesaurus ObjectClass)
C0015031 (UMLS 2011AA ObjectClass)
Item
Education Level
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17953 (NCI Thesaurus Property)
C0013658 (UMLS 2011AA Property)
C17953 (NCI Thesaurus ValueDomain)
C0013658 (UMLS 2011AA ValueDomain)
CL.5
Code List
Education Level
CL Item
Preschool Completion (Preschool)
C70433 (NCI Thesaurus)
C0681405 (UMLS 2011AA)
CL Item
Kindergarten Completion (Kindergarten)
C70432 (NCI Thesaurus)
C0681406 (UMLS 2011AA)
CL Item
1st Grade (1st Grade)
C67123 (NCI Thesaurus)
C1883619 (UMLS 2011AA)
CL Item
2nd Grade (2nd Grade)
C67124 (NCI Thesaurus)
C1883622 (UMLS 2011AA)
CL Item
3rd Grade (3rd Grade)
C67125 (NCI Thesaurus)
C1883635 (UMLS 2011AA)
CL Item
4th Grade (4th Grade)
C67126 (NCI Thesaurus)
C1883642 (UMLS 2011AA)
CL Item
5th Grade (5th Grade)
C67127 (NCI Thesaurus)
C1883646 (UMLS 2011AA)
CL Item
6th Grade (6th Grade)
C67128 (NCI Thesaurus)
C1883649 (UMLS 2011AA)
CL Item
7th Grade (7th Grade)
C67129 (NCI Thesaurus)
C1883651 (UMLS 2011AA)
CL Item
8th Grade (8th Grade)
C67130 (NCI Thesaurus)
C1883653 (UMLS 2011AA)
CL Item
9th Grade (9th Grade)
C67131 (NCI Thesaurus)
C1883654 (UMLS 2011AA)
CL Item
10th Grade (10th Grade)
C67132 (NCI Thesaurus)
C1883613 (UMLS 2011AA)
CL Item
11th Grade (11th Grade)
C67133 (NCI Thesaurus)
C1883614 (UMLS 2011AA)
CL Item
12th Grade (12th Grade No Diploma)
C67134 (NCI Thesaurus)
C1883615 (UMLS 2011AA)
CL Item
High School Graduate (High School Graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS 2011AA)
CL Item
General Equivalency Diploma (General Equivalency Diploma)
C67135 (NCI Thesaurus)
C1880947 (UMLS 2011AA)
CL Item
Bachelor's Degree Completion (Bachelor Degree)
C70555 (NCI Thesaurus)
C2346951 (UMLS 2011AA)
CL Item
Associate Degree (Associate Degree)
C67140 (NCI Thesaurus)
C1879750 (UMLS 2011AA)
CL Item
Academic Doctorate Degree Completion (Academic Doctorate Degree)
C70557 (NCI Thesaurus)
C2348318 (UMLS 2011AA)
CL Item
Master's Degree Completion (Master's Degree)
C70556 (NCI Thesaurus)
C2347079 (UMLS 2011AA)
CL Item
Professional Doctorate Degree Completion (Professional Doctorate Degree)
C70558 (NCI Thesaurus)
C2347690 (UMLS 2011AA)
CL Item
Vocational Degree (VoTech Program)
C67141 (NCI Thesaurus)
C1883542 (UMLS 2011AA)
CL Item
Never Attended (No Formal Schooling)
C67122 (NCI Thesaurus)
C0557286 (UMLS 2011AA)
CL Item
Refuse (Refused)
C49161 (NCI Thesaurus)
C1705116 (UMLS 2011AA)
CL Item
Some College (Some College, No Degree)
C67137 (NCI Thesaurus)
C1883065 (UMLS 2011AA)
CL Item
Does Not Know (Don't Know)
C67142 (NCI Thesaurus)
C1880386 (UMLS 2011AA)
Item
Marital Status
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25188 (NCI Thesaurus Property)
C0024819 (UMLS 2011AA Property)
CL.6
Code List
Marital Status
CL Item
Divorced: C51776 (Divorced)
C51776 (NCI Thesaurus)
C0086170 (UMLS 2011AA)
CL Item
Domestic Partner (Domestic Partnership)
C53262 (NCI Thesaurus)
C1549111 (UMLS 2011AA)
CL Item
Married: C51773 (Married)
C51773 (NCI Thesaurus)
C0555047 (UMLS 2011AA)
CL Item
Never Married (Never Married)
C51774 (NCI Thesaurus)
C0027952 (UMLS 2011AA)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS 2011AA)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
PersonGeographicBirthPlaceText
Item
Place of Birth
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
C25319 (NCI Thesaurus Property)
C0442504 (UMLS 2011AA Property)
C37957 (NCI Thesaurus Property)
C1517526 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25155 (NCI Thesaurus ValueDomain)
C0005615 (UMLS 2011AA ValueDomain)
C25319 (NCI Thesaurus ValueDomain)
C0442504 (UMLS 2011AA ValueDomain)
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