ID

6205

Beskrivning

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

Länk

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

Nyckelord

  1. 2014-12-18 2014-12-18 - Martin Dugas
  2. 2015-01-08 2015-01-08 - Martin Dugas
  3. 2021-09-20 2021-09-20 -
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18 december 2014

DOI

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Creative Commons BY-NC 3.0 Legacy

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NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104)

No Instruction available.

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

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Beskrivning

CoordinatingGroupProtocolNumber

Datatyp

text

Coordinating Group Code
Beskrivning

CoordinatingGroupCode

Datatyp

text

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

ProtocolTitle

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Participating Group Code
Beskrivning

ParticipatingGroupCode

Datatyp

text

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

PatientMedicalRecordNumber

Datatyp

text

Patient Study ID, Participating Group
Beskrivning

PatientStudyID,ParticipatingGroup

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Afiiliate
Beskrivning

AffiliateName

Datatyp

text

Physician of Record
Beskrivning

RegisteredInvestigator

Datatyp

text

Protocol Administration
Beskrivning

Protocol Administration

IRB/REB Approval Date
Beskrivning

IRB/REBApprovalDate

Datatyp

text

Person Completing Form, Last Name
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

Person Completing Form, First Name
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date Informed Consent Signed
Beskrivning

InformedConsentDateSigned

Datatyp

date

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

PersonCompletingForm,Phone

Datatyp

text

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

PersonCompletingForm,Fax

Datatyp

double

Projected Start Date of Treatment
Beskrivning

ProjectedTreatmentBeginDate

Datatyp

date

Date of Registration
Beskrivning

RegistrationDate

Datatyp

date

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

Patient Demographics / Pre-treatment Characteristics

Patient Name, Last (initials acceptable)
Beskrivning

PatientName,Last

Datatyp

text

Patient Name, First (initials acceptable)
Beskrivning

PatientName,First

Datatyp

text

Patient Name, Middle (initials acceptable)
Beskrivning

PatientName,Middle

Datatyp

text

Patient Birth Date (MM DD YYYY)
Beskrivning

PatientBirthDate

Datatyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Patient Gender
Beskrivning

PatientGender

Datatyp

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)
Beskrivning

PatientRace/Ethnicity

Datatyp

text

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

PatientSocialSecurityNumber

Datatyp

double

Street Address
Beskrivning

Address,Line1

Datatyp

text

City
Beskrivning

Address,City

Datatyp

text

State
Beskrivning

Address,StateCode

Datatyp

text

Patient?s ZIP Code (USA)
Beskrivning

PatientAddress,PostalCode

Datatyp

double

Country of Residence (if not USA)
Beskrivning

PatientAddress,Country

Datatyp

text

Patient Height (cm)
Beskrivning

PatientHeight

Datatyp

double

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

PatientWeight

Datatyp

double

Body Surface Area
Beskrivning

BodySurfaceArea

Datatyp

double

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

PerformanceStatus

Datatyp

text

Certification Of Eligibility
Beskrivning

Certification Of Eligibility

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

PatientEligibilityInd

Datatyp

text

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
Beskrivning

Protocol Design

Primary Tumor Pathological Stage
Beskrivning

TStage,Pathologic

Datatyp

text

Number of Nodes Involved By Tumor (check one)
Beskrivning

NumberofNodesInvolvedByTumor

Datatyp

text

Initial Patient Consent For Specimen Use
Beskrivning

Initial Patient Consent For Specimen Use

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

PatientInitialConsent,Specimen,Patient'scancerresearchInd

Datatyp

text

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

PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd

Datatyp

text

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

PatientInitialConsent,Specimen,ContactInd

Datatyp

text

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

InformedConsentDateSigned,SpecimenUse

Datatyp

date

Similar models

No Instruction available.

  1. StudyEvent: NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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)
ProtocolTitle
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA 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
double
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)
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/Ethnicity (check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
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
double
Address,Line1
Item
Street Address
text
Address,City
Item
City
text
Address,StateCode
Item
State
text
PatientAddress,PostalCode
Item
Patient?s ZIP Code (USA)
double
PatientAddress,Country
Item
Country of Residence (if not USA)
text
PatientHeight
Item
Patient Height (cm)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
PatientWeight
Item
Patient Weight (kg)
double
BodySurfaceArea
Item
Body Surface Area
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item
Performance Status (check one)
text
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
Item
In the opinion of the investigator is the patient eligible?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25171 (NCI Thesaurus Property)
C0013893 (UMLS 2011AA Property)
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
Item
Primary Tumor Pathological Stage
text
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
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
Item
Patient?s Initial Consent given for specimen use for research on the patient?s cancer?
text
Code List
Patient?s Initial Consent given for specimen use for research on the patient?s cancer?
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient?s Initial Consent given for specien use for research unrelated to the patient?s cancer?
text
Code List
Patient?s Initial Consent given for specien use for research unrelated to the patient?s cancer?
CL Item
Null (Yes)
CL Item
Null (No)
Item
Patient?s Initial Consent given for further contact regarding specimen?
text
Code List
Patient?s Initial Consent given for further contact regarding specimen?
CL Item
Null (Yes)
CL Item
Null (No)
InformedConsentDateSigned,SpecimenUse
Item
Date of Consent for Specimen Use (MM DD YYYY)
date

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