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ID

6043

Description

Phase II Breast Cancer Registration Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=23E49B63-1DBC-53B8-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=23E49B63-1DBC-53B8-E044-0003BA3F9857

Keywords

Versions (5)
  1. 9/19/12 9/19/12 -
  2. 11/26/14 11/26/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
  5. 9/17/21 9/17/21 -
Uploaded on

November 26, 2014

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License

Creative Commons BY-NC 3.0 Legacy
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    Registration - Phase II Breast Cancer Registration Form - 2550280v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: Phase II Breast Cancer Registration Form
      1. No Instruction available.
    Crf Header
    Description

    Crf Header

    Coordinating Group Protocol No.
    Description

    ProtocolCoordinatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25462
    UMLS 2011AA Property
    C0700114
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Coordinating Group Code
    Description

    CoordinatingGroupIdentifierCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus ObjectClass
    C25462
    UMLS 2011AA ObjectClass
    C0700114
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Protocol Title
    Description

    ProtocolTitleName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C42774
    UMLS 2011AA Property
    C1705823
    Patient Study ID
    Description

    PatientCoordinatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25462
    UMLS 2011AA Property
    C0700114
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Registering Group Code
    Description

    RegisteringGroupIdentifierCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25645
    Patient Medical Record Number
    Description

    PatientMedicalRecordNumber

    Data type

    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
    Other Patient ID
    Description

    PatientParticipatingIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution/Affiliate
    Description

    CombinedInstitutionName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Registering Institution Code
    Description

    RegisteringInstitutionIdentifierCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25645
    Physician of Record
    Description

    RegisteredInvestigatorName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    NCI Thesaurus ObjectClass
    C25644
    Form Administration
    Description

    Form Administration

    IRB/REB Approval Date
    Description

    ProtocolIRBApprovedDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C16741
    UMLS 2011AA Property
    C0086911
    NCI Thesaurus Property
    C25425
    UMLS 2011AA Property
    C0205540
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Date Informed Consent Signed
    Description

    InformedConsentFormSignedDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Date Informed Consent Expired
    Description

    ConsentFormSignedEndDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Projected Start Date of Treatment
    Description

    TreatmentProjectedBeginDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass
    C25631
    NCI Thesaurus Property
    C25431
    UMLS 2011AA Property
    C0439659
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25431
    UMLS 2011AA ValueDomain
    C0439659
    Date of Registration
    Description

    PatientRegistrationDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    HIPAA Authorization Date
    Description

    PatientSignedDischargeMedicalRecordDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25679
    NCI Metathesaurus Property
    C0012621
    NCI Thesaurus Property
    C45258
    UMLS 2011AA Property
    C0025102
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Date Form Completed
    Description

    FormCompleteDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ValueDomain
    C25367
    Person Completing Form, Last Name
    Description

    ResponsiblePersonLastName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25551
    UMLS 2011AA Property
    C1517741
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Person Completing Form, First Name
    Description

    ResponsiblePersonFirstName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Person Completing Form, Phone
    Description

    ResponsiblePersonPhoneNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    Person Completing Form, Fax
    Description

    ResponsiblePersonFaxNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25210
    UMLS 2011AA Property
    C0085205
    Patient Demographics / Pre-treatment Characteristics
    Description

    Patient Demographics / Pre-treatment Characteristics

    Patient Name (initials acceptable)
    Description

    PatientName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Birth Date
    Description

    PatientBirthDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C25155
    UMLS 2011AA Property
    C0005615
    Patient Gender
    Description

    PatientGenderCategory

    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 (check all that applyU.S. and Canada only)
    Description

    PatientRaceCategory

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    Patient Ethnicity (U.S. and Canada only)
    Description

    PatientEthnicGroupCategory

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C16564
    UMLS 2011AA Property
    C0015031
    Patient Social Security Number (USA only)
    Description

    PatientSSNNumber

    Data type

    double

    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 Zip Code (USA)
    Description

    PatientAddressPostalCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25407
    UMLS 2011AA Property
    C1442065
    Country of Residence (if not USA)
    Description

    PatientAddressCountryName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain
    C25464
    UMLS 2011AA ValueDomain
    C0454664
    NCI Thesaurus Property
    C25407
    UMLS 2011AA Property
    C1442065
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Patient Height (cm)
    Description

    PatientHeightMeasurement

    Data type

    double

    Measurement units
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25347
    UMLS 2011AA Property
    C0489786
    cm
    Patient Weight (kg)
    Description

    PatientWeightMeasurement

    Data type

    double

    Measurement units
    • Kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25208
    UMLS 2011AA Property
    C0043100
    Kg
    Body Surface Area (m^2)
    Description

    PatientBodySurfaceAreaMeasurement

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25157
    UMLS 2011AA Property
    C0005902
    ECOG Performance Status (check one)
    Description

    PerformanceStatusAssessmentEasternCooperativeOncologyGroupScale

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain
    C25491
    UMLS 2011AA ValueDomain
    C1512162
    NCI Thesaurus ObjectClass
    C20641
    UMLS 2011AA ObjectClass
    C1518965
    Karnofsky Performance Status Score (check one)
    Description

    KarnofskyPerformanceStatusScore

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ObjectClass
    C20641
    UMLS 2011AA ObjectClass
    C1518965
    NCI Thesaurus ValueDomain
    C25338
    UMLS 2011AA ValueDomain
    C0449820
    Method of Payment (check oneUSA only)
    Description

    PatientPaymentType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25371
    UMLS 2011AA Property
    C0680264
    Certification Of Eligibility
    Description

    Certification Of Eligibility

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

    PatientEligibilityIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    Protocol Design
    Description

    Protocol Design

    Stratification Factors (protocol specific)
    Description

    StudyStratificationText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15206
    UMLS 2011AA ObjectClass
    C0008972
    NCI Thesaurus Property
    C25689
    UMLS 2011AA Property
    C1514983
    Assigned Treatment Arm (protocol specific)
    Description

    TreatmentArmNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C32141
    UMLS 2011AA Property
    C1140618
    NCI Thesaurus ObjectClass
    C15368
    Treatment Assignment Code (protocol specific)
    Description

    TreatmentAssignmentCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25426
    UMLS 2011AA Property
    C1516050
    NSC Number (Please check the CTEP Home Page for a list of agent NSC numbers.)
    Description

    AgentNSC/GPIIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C41244
    Agent Name
    Description

    AgentName

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ValueDomain
    C1708
    UMLS 2011AA ValueDomain
    C0450442
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    Agent Dose
    Description

    AgentAdministeredDose

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25488
    UMLS 2011AA ValueDomain
    C0178602
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ValueDomain
    C1708
    UMLS 2011AA ValueDomain
    C0450442
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Units
    Description

    AgentDoseUOM

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus Property
    C25256
    UMLS 2011AA Property
    C1265611
    NCI Thesaurus ValueDomain
    C25709
    UMLS 2011AA ValueDomain
    C1519795
    Route
    Description

    Drug Administration Route

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C0013153
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus ObjectClass
    C25409
    NCI Thesaurus Property
    C25169
    Frequency
    Description

    AgentAdministeredFrequency

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C1708
    UMLS 2011AA ObjectClass
    C0450442
    NCI Thesaurus ValueDomain
    C25515
    UMLS 2011AA ValueDomain
    C0439603
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Schedule
    Description

    TherapeuticAgentsAdministeredScheduleText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25211
    UMLS 2011AA Property
    C0086960
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    NCI Thesaurus ObjectClass
    C17935
    UMLS 2011AA ObjectClass
    C1611640
    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

    SpecimenResearchConsentRelatedInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C15319
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    Patient's Initial Consent given for specimen use for research unrelated to the patient's cancer?
    Description

    BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C12801
    UMLS 2011AA ObjectClass
    C0040300
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property
    C2991
    UMLS 2011AA Property
    C0012634
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Patient's initial consent given for further contact regarding specimen?
    Description

    PatientContactConsentInd-3

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C67527
    UMLS 2011AA Property
    C0016884
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus Property
    C16452
    UMLS 2011AA Property
    C0009452
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Date of Consent for Specimen Use
    Description

    SpecimenICFSignedDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25679
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
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    1. StudyEvent: Phase II Breast Cancer Registration Form
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    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Crf Header
    ProtocolCoordinatingIdentifierNumber
    Item
    Coordinating Group Protocol No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25462 (NCI Thesaurus Property)
    C0700114 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CoordinatingGroupIdentifierCode
    Item
    Coordinating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25462 (NCI Thesaurus ObjectClass)
    C0700114 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolTitleName
    Item
    Protocol Title
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C42774 (NCI Thesaurus Property)
    C1705823 (UMLS 2011AA Property)
    PatientCoordinatingIdentifierNumber
    Item
    Patient Study ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25462 (NCI Thesaurus Property)
    C0700114 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    RegisteringGroupIdentifierCode
    Item
    Registering Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25645 (NCI Thesaurus ObjectClass)
    PatientMedicalRecordNumber
    Item
    Patient Medical Record Number
    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)
    PatientParticipatingIdentifierNumber
    Item
    Other Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CombinedInstitutionName
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    RegisteringInstitutionIdentifierCode
    Item
    Registering Institution Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25645 (NCI Thesaurus ObjectClass)
    RegisteredInvestigatorName
    Item
    Physician of Record
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    C25644 (NCI Thesaurus ObjectClass)
    Item Group
    Form Administration
    ProtocolIRBApprovedDate
    Item
    IRB/REB Approval Date
    date
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C16741 (NCI Thesaurus Property)
    C0086911 (UMLS 2011AA Property)
    C25425 (NCI Thesaurus Property)
    C0205540 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    ConsentFormSignedEndDate
    Item
    Date Informed Consent Expired
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    TreatmentProjectedBeginDate
    Item
    Projected Start Date of Treatment
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25631 (NCI Thesaurus ObjectClass)
    C25431 (NCI Thesaurus Property)
    C0439659 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain)
    C0439659 (UMLS 2011AA ValueDomain)
    PatientRegistrationDate
    Item
    Date of Registration
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    PatientSignedDischargeMedicalRecordDate
    Item
    HIPAA Authorization Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C0012621 (NCI Metathesaurus Property)
    C45258 (NCI Thesaurus Property)
    C0025102 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    FormCompleteDate
    Item
    Date Form Completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    ResponsiblePersonLastName
    Item
    Person Completing Form, Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus Property)
    C1517741 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    ResponsiblePersonFirstName
    Item
    Person Completing Form, First Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    ResponsiblePersonPhoneNumber
    Item
    Person Completing Form, Phone
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    ResponsiblePersonFaxNumber
    Item
    Person Completing Form, Fax
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25210 (NCI Thesaurus Property)
    C0085205 (UMLS 2011AA Property)
    Item Group
    Patient Demographics / Pre-treatment Characteristics
    PatientName
    Item
    Patient Name (initials acceptable)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientBirthDate
    Item
    Patient Birth Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C25155 (NCI Thesaurus Property)
    C0005615 (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)
    C0015780 (UMLS 2011AA)
    Item
    Patient Race (check all that applyU.S. and Canada only)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    CL.2
    Code List
    Patient Race (check all that applyU.S. and Canada only)
    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
    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 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
    Not Provided Or Available (Not Reported)
    C43234 (NCI Thesaurus)
    C1706613 (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 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
    Could Not Be Determined Or Unsure (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Patient Ethnicity (U.S. and Canada only)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C16564 (NCI Thesaurus Property)
    C0015031 (UMLS 2011AA Property)
    CL.3
    Code List
    Patient Ethnicity (U.S. and Canada only)
    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
    Could Not Be Determined Or Unsure (UNKNOWN)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    PatientSSNNumber
    Item
    Patient Social Security Number (USA only)
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25686 (NCI Thesaurus Property)
    C1301821 (UMLS 2011AA Property)
    PatientAddressPostalCode
    Item
    Patient Zip Code (USA)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25407 (NCI Thesaurus Property)
    C1442065 (UMLS 2011AA Property)
    PatientAddressCountryName
    Item
    Country of Residence (if not USA)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25464 (NCI Thesaurus ValueDomain)
    C0454664 (UMLS 2011AA ValueDomain)
    C25407 (NCI Thesaurus Property)
    C1442065 (UMLS 2011AA Property)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    PatientHeightMeasurement
    Item
    Patient Height (cm)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS 2011AA Property)
    PatientWeightMeasurement
    Item
    Patient Weight (kg)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25208 (NCI Thesaurus Property)
    C0043100 (UMLS 2011AA Property)
    PatientBodySurfaceAreaMeasurement
    Item
    Body Surface Area (m^2)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25157 (NCI Thesaurus Property)
    C0005902 (UMLS 2011AA Property)
    Item
    ECOG Performance Status (check one)
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain)
    C1512162 (UMLS 2011AA ValueDomain)
    C20641 (NCI Thesaurus ObjectClass)
    C1518965 (UMLS 2011AA ObjectClass)
    CL.4
    Code List
    ECOG Performance Status (check one)
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    Item
    Karnofsky Performance Status Score (check one)
    text
    C25367 (NCI Thesaurus Property)
    C20641 (NCI Thesaurus ObjectClass)
    C1518965 (UMLS 2011AA ObjectClass)
    C25338 (NCI Thesaurus ValueDomain)
    C0449820 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Karnofsky Performance Status Score (check one)
    CL Item
    Normal, No Complaints, No Evidence Of Disease (100)
    CL Item
    Able To Carry On Normal Activity; Minor Signs Or Symptoms Of Disease (90)
    CL Item
    Normal Activity With Effort; Some Signs Or Symptoms Of Disease (80)
    CL Item
    Cares For Self, Unable To Carry On Normal Activity Or To Do Active Work (70)
    CL Item
    Requires Occasional Assistance, But Is Able To Care For Most Of His/her Needs (60)
    CL Item
    Requires Considerable Assistance And Frequent Medical Care (50)
    CL Item
    Disabled, Requires Special Care And Assistance (40)
    CL Item
    Severely Disabled, Hospitalization Indicated. Death Not Imminent (30)
    CL Item
    Very Sick, Hospitalization Indicated. Death Not Imminent (20)
    CL Item
    Moribund, Fatal Processes Progressing Rapidly (10)
    Item
    Method of Payment (check oneUSA only)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25371 (NCI Thesaurus Property)
    C0680264 (UMLS 2011AA Property)
    CL.6
    Code List
    Method of Payment (check oneUSA only)
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    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)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item Group
    Certification Of Eligibility
    Item
    In the opinion of the investigator, is the patient eligible?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    CL.7
    Code List
    In the opinion of the investigator, is the patient eligible?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Protocol Design
    StudyStratificationText
    Item
    Stratification Factors (protocol specific)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15206 (NCI Thesaurus ObjectClass)
    C0008972 (UMLS 2011AA ObjectClass)
    C25689 (NCI Thesaurus Property)
    C1514983 (UMLS 2011AA Property)
    TreatmentArmNumber
    Item
    Assigned Treatment Arm (protocol specific)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C32141 (NCI Thesaurus Property)
    C1140618 (UMLS 2011AA Property)
    C15368 (NCI Thesaurus ObjectClass)
    TreatmentAssignmentCode
    Item
    Treatment Assignment Code (protocol specific)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25426 (NCI Thesaurus Property)
    C1516050 (UMLS 2011AA Property)
    AgentNSC/GPIIdentifierNumber
    Item
    NSC Number (Please check the CTEP Home Page for a list of agent NSC numbers.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C41244 (NCI Thesaurus Property)
    AgentName
    Item
    Agent Name
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C0450442 (UMLS 2011AA ValueDomain)
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    AgentAdministeredDose
    Item
    Agent Dose
    double
    C25488 (NCI Thesaurus ValueDomain)
    C0178602 (UMLS 2011AA ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ValueDomain)
    C0450442 (UMLS 2011AA ValueDomain)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    Item
    Units
    text
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25256 (NCI Thesaurus Property)
    C1265611 (UMLS 2011AA Property)
    C25709 (NCI Thesaurus ValueDomain)
    C1519795 (UMLS 2011AA ValueDomain)
    CL.8
    Code List
    Units
    CL Item
    Billion Pfu (billion pfu)
    CL Item
    Cells (cells)
    CL Item
    Centigrays (cGy)
    CL Item
    Curie (Ci)
    C0700085 (NCI Metathesaurus)
    CL Item
    Centimeter (cm)
    C49668 (NCI Thesaurus)
    C0475210 (UMLS 2011AA)
    CL Item
    Deciliter (dL)
    CL Item
    Decimeter (dm)
    CL Item
    Gram-equivalent Weight (Eq)
    CL Item
    Gram (g)
    C0439208 (NCI Metathesaurus)
    CL Item
    Gravity (in Centrifugation) (gravity)
    CL Item
    Grays (Gy)
    CL Item
    Hertz (Hz)
    CL Item
    International Unit (IU)
    C28255 (NCI Thesaurus)
    CL Item
    Joules Per Centimeter Square (J/cm^2)
    CL Item
    Kilo-electron Volt (keV)
    CL Item
    Kilogram (kg)
    C28252 (NCI Thesaurus)
    C0439209 (UMLS 2011AA)
    CL Item
    Kilohertz (kHz)
    CL Item
    Kilopascal (kPa)
    CL Item
    Liter (L)
    CL Item
    Meter (m)
    C0475209 (NCI Metathesaurus)
    CL Item
    Microcurie (mcCi)
    CL Item
    Microgram (mcg)
    CL Item
    Millicurie (mCi)
    CL Item
    Microliter (mcL)
    CL Item
    Micrometer (mcm)
    CL Item
    Micromole (mcmol)
    C48509 (NCI Thesaurus)
    C0439194 (UMLS 2011AA)
    CL Item
    Milliequivalent (mEq)
    CL Item
    Million Electron Volts (MeV)
    CL Item
    Milligram (mg)
    C28253 (NCI Thesaurus)
    C0439210 (UMLS 2011AA)
    CL Item
    Megahertz (MHz)
    CL Item
    Million International Units (million IU)
    CL Item
    Million Pfu (million pfu)
    CL Item
    Milliunit (milliunit)
    CL Item
    Milliliter (mL)
    C28254 (NCI Thesaurus)
    C0439242 (UMLS 2011AA)
    CL Item
    Millimeter (mm)
    C28251 (NCI Thesaurus)
    C0439200 (UMLS 2011AA)
    CL Item
    Milligrams Per Milliliter Per Minute (MMM)
    CL Item
    Millimole (mmol)
    CL Item
    Gram-molecular Weight (mole) (mol)
    CL Item
    Milliosmole (mOsmol)
    CL Item
    Megarad (Mrad)
    CL Item
    Million Unit (MU)
    CL Item
    Millivolt (mV)
    C0456691 (NCI Metathesaurus)
    CL Item
    Million Viral Particles (mVP)
    C67351 (NCI Thesaurus)
    C1881847 (UMLS 2011AA)
    CL Item
    Not Applicable (N/A)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Nanocurie (nCi)
    C0560007 (NCI Metathesaurus)
    CL Item
    Nanogram (ng)
    CL Item
    Nanometer (nm)
    C0439202 (NCI Metathesaurus)
    CL Item
    Nanometers Of Light (nm light)
    CL Item
    Osmole (Osmol)
    CL Item
    Pascal (Pa)
    C42547 (NCI Thesaurus)
    C0439473 (UMLS 2011AA)
    CL Item
    Percent (percent)
    C48570 (NCI Thesaurus)
    C0439165 (UMLS 2011AA)
    CL Item
    Plaque Forming Unit (pfu)
    CL Item
    Picogram (pg)
    C0439213 (NCI Metathesaurus)
    CL Item
    Pounds Per Square Inch (psi)
    C0439472 (NCI Metathesaurus)
    CL Item
    Tissue Culture Infections Dose (TCID)
    CL Item
    Unit (unit)
    C44278 (NCI Thesaurus)
    C0439148 (UMLS 2011AA)
    CL Item
    Viral Particles (VP)
    Item
    Route
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0013153 (UMLS CUI-1)
    C459 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus ObjectClass)
    C25169 (NCI Thesaurus Property)
    CL.9
    Code List
    Route
    CL Item
    Intramuscular (IM)
    C27974 (NCI Thesaurus)
    C0442117 (UMLS 2011AA)
    C27974 (NCI Thesaurus)
    C0442117 (UMLS 2011AA)
    CL Item
    Intravenous (IV)
    X-MO-6794 (MGED)
    X-MO-6794 (MGED)
    CL Item
    Oral (PO)
    C25311 (NCI Thesaurus)
    C0442027 (UMLS 2011AA)
    C25311 (NCI Thesaurus)
    C0442027 (UMLS 2011AA)
    CL Item
    Oral (oral)
    C25311 (NCI Thesaurus)
    C0442027 (UMLS 2011AA)
    C25311 (NCI Thesaurus)
    C0442027 (UMLS 2011AA)
    CL Item
    Transdermal (Transdermal)
    C28017 (NCI Thesaurus)
    C0694643 (UMLS 2011AA)
    CL Item
    Topical (Topical)
    C13344 (NCI Thesaurus)
    C0332237 (UMLS 2011AA)
    C13344 (NCI Thesaurus)
    C0332237 (UMLS 2011AA)
    CL Item
    Intravenous (intravenous)
    X-MO-6794 (MGED)
    X-MO-6794 (MGED)
    CL Item
    Subcutaneous (Subcutaneous)
    C13353 (NCI Thesaurus)
    C0443315 (UMLS 2011AA)
    C13353 (NCI Thesaurus)
    C0443315 (UMLS 2011AA)
    CL Item
    Vaginal (vaginal)
    CL Item
    Nasal (Nasal)
    C27958 (NCI Thesaurus)
    C0028429 (UMLS 2011AA)
    Item
    Frequency
    text
    C1708 (NCI Thesaurus ObjectClass)
    C0450442 (UMLS 2011AA ObjectClass)
    C25515 (NCI Thesaurus ValueDomain)
    C0439603 (UMLS 2011AA ValueDomain)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    CL.10
    Code List
    Frequency
    CL Item
    After Meals (p.c.) (after meals (P.C.))
    CL Item
    Am (AM)
    CL Item
    As Needed (p.r.n) (as needed (P.R.N))
    CL Item
    At Bedtime Or Hour Of Sleep (h.s.) (at bedtime or hour of sleep (H.S.))
    CL Item
    Before Meals (a.c.) (before meals (A.C.))
    CL Item
    Daily (Daily)
    C25473 (NCI Thesaurus)
    C0332173 (UMLS 2011AA)
    CL Item
    Every 1 To 2 Hours (Every 1 to 2 hours)
    CL Item
    Every 10 Hours (Every 10 hours)
    CL Item
    Every 11 Hours (Every 11 hours)
    CL Item
    Every 12 Hours (q12hr) (every 12 hours (Q12hr))
    CL Item
    Every 13 Hours (Every 13 hours)
    CL Item
    Every 14 Hours (Every 14 hours)
    CL Item
    Every 15 Hours (Every 15 hours)
    CL Item
    Every 16 Hours (Every 16 hours)
    CL Item
    Every 17 Hours (Every 17 hours)
    CL Item
    Every 18 Hours (Every 18 hours)
    CL Item
    Every 19 Hours (Every 19 hours)
    CL Item
    Every 2 Hours (Every 2 hours)
    CL Item
    Every 20 Hours (Every 20 hours)
    CL Item
    Every 21 Hours (Every 21 hours)
    CL Item
    Every 22 Hours (Every 22 hours)
    CL Item
    Every 23 Hours (Every 23 hours)
    CL Item
    Every 24 Hours (Every 24 hours)
    CL Item
    Every 3 Hours (Every 3 hours)
    CL Item
    Every 3 To 4 Hours (Every 3 to 4 hours)
    CL Item
    Every 4 Hours (q4hr) (every 4 hours (Q4hr))
    CL Item
    Every 4 To 5 Hours (Every 4 to 5 hours)
    CL Item
    Every 4 To 6 Hours (Every 4 to 6 hours)
    CL Item
    Every 5 Hours (Every 5 hours)
    CL Item
    Every 6 Hours (Every 6 hours)
    CL Item
    Every 6 Hours (q6hr) (every 6 hours (Q6hr))
    CL Item
    Every 7 Hours (Every 7 hours)
    CL Item
    Every 8 Hours (q8hr) (every 8 hours (Q8hr))
    CL Item
    Every 9 Hours (Every 9 hours)
    CL Item
    Every Day (q.d.) (every day (Q.D.))
    CL Item
    Every Evening (Every evening)
    CL Item
    Every Hour (Every hour)
    CL Item
    Every Morning (Every morning)
    CL Item
    Every Other Day (q.o.d.) (every other day (Q.O.D.))
    CL Item
    Five Times Daily (Five times daily)
    CL Item
    Four Times A Day (q.i.d) (four times a day (Q.I.D))
    CL Item
    Immediately (stat) (immediately (Stat))
    CL Item
    Monthly (Monthly)
    CL Item
    Not Specified (Not specified)
    CL Item
    Once A Day (q.d.) (Once a day (Q.D.))
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Pm/bedtime (PM/bedtime)
    CL Item
    Three Times A Day (t.i.d) (three times a day (T.I.D))
    CL Item
    Three Times A Week (t.i.w) (three times a week (T.I.W))
    CL Item
    Twice A Day (b.i.d) (twice a day (B.I.D))
    CL Item
    Twice A Week (b.i.w) (twice a week (B.I.W))
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Weekly (Weekly)
    CL158132 (NCI Metathesaurus)
    TherapeuticAgentsAdministeredScheduleText
    Item
    Schedule
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25211 (NCI Thesaurus Property)
    C0086960 (UMLS 2011AA Property)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    C17935 (NCI Thesaurus ObjectClass)
    C1611640 (UMLS 2011AA ObjectClass)
    Item Group
    Initial Patient Consent For Specimen Use
    Item
    Patient's Initial Consent given for specimen use for research on the patient's cancer?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    CL.11
    Code List
    Patient's Initial Consent given for specimen use for research on the patient's cancer?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Patient's Initial Consent given for specimen use for research unrelated to the patient's cancer?
    text
    C12801 (NCI Thesaurus ObjectClass)
    C0040300 (UMLS 2011AA ObjectClass)
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C15319 (NCI Thesaurus Property)
    C2991 (NCI Thesaurus Property)
    C0012634 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.12
    Code List
    Patient's Initial Consent given for specimen use for research unrelated to the patient's cancer?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Patient's initial consent given for further contact regarding specimen?
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C67527 (NCI Thesaurus Property)
    C0016884 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C16452 (NCI Thesaurus Property)
    C0009452 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.13
    Code List
    Patient's initial consent given for further contact regarding specimen?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    SpecimenICFSignedDate
    Item
    Date of Consent for Specimen Use
    date
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
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