PatientFirstInitialsName
Item
First initial
text
PatientLastInitialsName
Item
Last initial
text
Item
Has the eligibility checklist been completed
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25171 (NCI Thesaurus ObjectClass)
C0013893 (UMLS 2011AA ObjectClass)
C49073 (NCI Thesaurus Property)
C1707357 (UMLS 2011AA Property)
Code List
Has the eligibility checklist been completed
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
Code List
In the opinion of the investigator, is the patient eligible?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Has written informed consent been obtained
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
Code List
Has written informed consent been obtained
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
Item
Has HIPAA authorization been obtained
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C62504 (NCI Thesaurus ObjectClass)
C0600593 (UMLS 2011AA ObjectClass)
C41192 (NCI Thesaurus Property)
C1524004 (UMLS 2011AA Property)
Code List
Has HIPAA authorization been obtained
CL Item
No: C49487 (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes: C49488 (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Exempt - Non-usa Participant (Exempt - non-USA participant)
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)
Item
Planned Chemotherapy Regimen
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
Code List
Planned Chemotherapy Regimen
CL Item
Cisplatin And Vinorelbine (Cisplatin and Vinorelbine)
CL Item
Cisplatin And Docetaxel (Cisplatin and Docetaxel)
CL Item
Cisplatin And Gemcitabine (Cisplatin and Gemcitabine)
CL Item
Cisplatin And Pemetrexed (Cisplatin and pemetrexed)
Item
What is the patient's stage of disease
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C16112 (NCI Thesaurus Property)
C1516637 (UMLS 2011AA Property)
C38027 (NCI Thesaurus Property)
C1519504 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
What is the patient's stage of disease
CL Item
Stage Ib >/= 4 Cm (Stage IB >/= 4 cm)
CL Item
Stage Ii Lung Cancer (Stage II)
CL Item
Stage Iiia-n2 Lung Cancer (Stage IIIA-N2)
CL Item
Stage Iiia-t3n1 Lung Cancer (Stage IIIA-T3N1)
Item
Histology
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus ObjectClass)
C0024109 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Non-small Cell Lung Carcinoma (Other Non-Small Cell Lung Cancer)
C2926 (NCI Thesaurus)
C0007131 (UMLS 2011AA)
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 Item
Male (MALE)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (FEMALE)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
Item
I agree to donate additional blood for research.
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25168 (NCI Thesaurus Property)
C0040288 (UMLS 2011AA Property)
C12434 (NCI Thesaurus Property)
C0229664 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
I agree to donate additional blood for research.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease) (for example: causes of diabetes, Alzheimer's disease, and heart disease)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C12801 (NCI Thesaurus Property)
C0040300 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease) (for example: causes of diabetes, Alzheimer's disease, and heart disease)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Someone may contact me in the future to ask me to allow other uses of my specimens.
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)
Code List
Someone may contact me in the future to ask me to allow other uses of my specimens.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PatientBirthDate
Item
Birthdate (mm/yy)
date
AddressPostalCodeIdentifier
Item
ZIP Code
text
Item
Patient Ethnicity
text
Code List
Patient 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)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
CL Item
Not Provided Or Available (Not reported)
CL Item
Could Not Be Determined Or Unsure (Unknown)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
PatientSSNNumber
Item
Patient Social Security Number
text
Item
Method of payment (check one)
text
Code List
Method of payment (check one)
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare (Medicare)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
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
Unknown (Unknown)
AttendingPhysicianIdentifierIndividualsName
Item
Attending Physician
text
InstitutionContactPersonName
Item
Institution contact
text
ProtocolRegistrarName
Item
Registrar
text
Item
Country of residence
text
Code List
Country of residence
CL Item
Ascension Island (AC)
CL Item
United Arab Emirates (AE)
CL Item
Antigua And Barbuda (AG)
CL Item
Netherland Antilles (AN)
CL Item
American Samoa (AS)
CL Item
Bosnia-herzegovina (BA)
CL Item
Burkina Faso (BF)
CL Item
Brunei Darussalam (BN)
CL Item
Bouvet Island (BV)
CL Item
Rep. Dem. Congo (CD)
CL Item
Central African Rep. (CF)
CL Item
Cook Islands (CK)
CL Item
Christmas Island (CX)
CL Item
Czech Republic (CZ)
CL Item
Dominican Republic (DO)
CL Item
Western Sahara (EH)
CL Item
Falkland Isl. (FK)
CL Item
Faroe Islands (FO)
CL Item
France (european Ter.) (FX)
CL Item
Great Britain (GB)
CL Item
Guiana (fr.) (GF)
CL Item
Guadeloupe (fr.) (GP)
CL Item
Equatorial Guinea (GQ)
CL Item
South Georgia And South Sandwich Islands (GS)
CL Item
Guinea Bissau (GW)
CL Item
Heard & Mcdonald Isl. (HM)
CL Item
British Indian O. Ter. (IO)
CL Item
Kyrgyz Republic (KG)
CL Item
St. Kitts Nevis Anguilla (KN)
CL Item
Korea (north) (KP)
CL Item
Korea (south) (KR)
CL Item
Cayman Islands (KY)
CL Item
Liechtenstein (LI)
CL Item
Marshall Islands (MH)
CL Item
Northern Mariana Isl. (MP)
CL Item
Martinique (fr.) (MQ)
CL Item
New Caledonia (fr.) (NC)
CL Item
Norfolk Island (NF)
CL Item
Polynesia (fr.) (PF)
CL Item
Papua New Guinea (PG)
CL Item
St. Pierre & Miquelon (PM)
CL Item
Reunion (fr.) (RE)
CL Item
Russian Federation (RU)
CL Item
Saudi Arabia (SA)
CL Item
Solomon Islands (SB)
CL Item
Svalbard & Jan Mayen Isl. (SJ)
CL Item
Sierra Leone (SL)
CL Item
St. Tome And Principe (ST)
CL Item
Soviet Union (SU)
CL Item
Turks & Caicos Islands (TC)
CL Item
French Southern Terr. (TF)
CL Item
Turkmenistan (TM)
CL Item
Trinidad & Tobago (TT)
CL Item
United Kingdom (UK)
CL Item
Us Minor Outlying Isl. (UM)
CL Item
Vatican City State (VA)
CL Item
St. Vincent & Grenadines (VC)
CL Item
Virgin Islands (brit) (VG)
CL Item
Virgin Islands (us) (VI)
CL Item
Wallis & Futuna Islands (WF)
CL Item
Western Samoa (WS)
CL Item
South Africa (ZA)
CL Item
Dem. Rep. Of Congo (ZR)
ResearchCommentsText
Item
Comments
text