ID
594
Description
CALGB 90104 Registration Worksheet Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B0241-438C-6AC6-E034-0003BA12F5E7
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 7/30/15 7/30/15 - Martin Dugas
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT00014534 Registration - CALGB 90104 Registration Worksheet - 2169258v3.0
No Instruction available.
- StudyEvent: CALGB 90104 Registration Worksheet
Description
Ccrr Module For Calgb 90104 Registration Worksheet
Description
InstitutionName
Data type
text
Description
AffiliateInstitution
Data type
text
Description
PhysicianofRecord
Data type
text
Description
ParticipatingGroupName
Data type
text
Description
CALGBPatientID
Data type
text
Description
IRBApprovalDate
Data type
text
Description
DateInformedConsentSigned
Data type
text
Description
ProjectedTreatmentStartDate
Data type
text
Description
HIPAAAuthorizationDate
Data type
text
Description
Responsiblecontact
Data type
text
Description
phone
Data type
text
Description
fax
Data type
text
Description
PatientInitials
Data type
text
Description
PatientSocialSecurityNumber
Data type
text
Description
PatientBirthDate
Data type
text
Description
PatientHospitalNo.
Data type
text
Description
Gender
Data type
text
Description
Race
Data type
text
Description
PerformanceStatus(ECOG/Zubrod)
Data type
text
Description
Height
Data type
text
Description
Weight
Data type
text
Description
BodySurfaceArea
Data type
text
Description
MethodofPayment
Data type
text
Description
Patient'szipcode
Data type
text
Description
Countryofresidence(ifnotUSA)
Data type
text
Description
Tstatus
Data type
text
Description
Lymphnodeinvolvement
Data type
text
Similar models
No Instruction available.
- StudyEvent: CALGB 90104 Registration Worksheet