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ID
6424
Description
E1905 Registration Worksheet (step 1) Azacitidine With or Without Entinostat in Treating Patients With Myelodysplastic Syndromes, Chronic Myelomonocytic Leukemia, or Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=74CCB3AB-1C3F-A75A-E040-BB89AD431F27
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Keywords
Versions (4)
- 12/18/14 12/18/14 - Martin Dugas
- 12/22/14 12/22/14 - Martin Dugas
- 1/9/15 1/9/15 - Martin Dugas
- 9/17/21 9/17/21 -
Uploaded on
December 22, 2014
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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E1905 Registration Worksheet (step 1)
No Instruction available.
- StudyEvent: E1905 Registration Worksheet (step 1)
Similar models
No Instruction available.
- StudyEvent: E1905 Registration Worksheet (step 1)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Eligibility checklist completed
Item
Has the eligibility checklist been completed
boolean
C38147 (NCI Thesaurus ValueDomain)
C25250 (NCI Thesaurus Property)
C25171 (NCI Thesaurus ObjectClass)
C49073 (NCI Thesaurus Property)
C0013893 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
C25250 (NCI Thesaurus Property)
C25171 (NCI Thesaurus ObjectClass)
C49073 (NCI Thesaurus Property)
C0013893 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
Patient eligible
Item
In the opinion of the investigator, is the patient eligible?
boolean
C38148 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
C1302261 (UMLS CUI-1)
Informed consent
Item
Has written informed consent been obtained
boolean
C38147 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25678 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property)
C0021430 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25678 (NCI Thesaurus Property)
C25460 (NCI Thesaurus Property)
C0021430 (UMLS CUI-1)
Item
Patient's simplified disease code
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C16112 (NCI Thesaurus Property)
C1516637 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C16112 (NCI Thesaurus Property)
C1516637 (UMLS 2011AA Property)
CL Item
Acute Myeloid Leukemia (Acute Myeloid Leukemia, NOS)
C3171 (NCI Thesaurus)
C0023467 (UMLS 2011AA)
C0023467 (UMLS 2011AA)
CL Item
Chronic Myelomonocytic Leukemia (Chronic Myelomonocytic Leukemia)
C3178 (NCI Thesaurus)
C0023480 (UMLS 2011AA)
C0023480 (UMLS 2011AA)
CL Item
Mds (Myelodysplastic syndrome, NOS)
C3247 (NCI Thesaurus)
C0026986 (UMLS 2011AA)
C0026986 (UMLS 2011AA)
Informed Consent Date
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C16468 (NCI Thesaurus ObjectClass)
C25679 (NCI Thesaurus Property)
C2985782 (UMLS CUI-1)
C25367 (NCI Thesaurus ValueDomain)
C16468 (NCI Thesaurus ObjectClass)
C25679 (NCI Thesaurus Property)
C2985782 (UMLS CUI-1)
Item
Has HIPAA authorization been obtained
integer
C25180 (NCI Thesaurus ValueDomain)
C62504 (NCI Thesaurus ObjectClass)
C41192 (NCI Thesaurus Property)
C0600593 (UMLS CUI-1)
C0680281 (UMLS CUI-2)
C62504 (NCI Thesaurus ObjectClass)
C41192 (NCI Thesaurus Property)
C0600593 (UMLS CUI-1)
C0680281 (UMLS CUI-2)
CL Item
No: C49487 (0)
CL Item
Yes: C49488 (1)
CL Item
Exempt - Non-USA Participant (2)
HIPAA Authorization Date
Item
HIPAA Authorization Date
date
C16960 (NCI Thesaurus ObjectClass)
C25679 (NCI Thesaurus Property)
C0012621 (NCI Metathesaurus Property)
C45258 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0600593 (UMLS CUI-1)
C0680281 (UMLS CUI-2)
C0011008 (UMLS CUI-3)
C25679 (NCI Thesaurus Property)
C0012621 (NCI Metathesaurus Property)
C45258 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0600593 (UMLS CUI-1)
C0680281 (UMLS CUI-2)
C0011008 (UMLS CUI-3)
Disease treatment induced
Item
Is the disease treatment-induced
boolean
C25190 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus Property)
C49236 (NCI Thesaurus Property)
C16112 (NCI Thesaurus Property)
C16390 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C2991 (NCI Thesaurus Property)
C49236 (NCI Thesaurus Property)
C16112 (NCI Thesaurus Property)
C16390 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
Item
Disease site/type
text
C25190 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus Property)
C49236 (NCI Thesaurus Property)
C16112 (NCI Thesaurus Property)
C16390 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C2991 (NCI Thesaurus Property)
C49236 (NCI Thesaurus Property)
C16112 (NCI Thesaurus Property)
C16390 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
CL Item
Mds High/int-2 (MDS High/Int-2)
CL Item
Mds Low/int-1 (MDS Low/Int-1)
CL Item
Chronic Myelomonocytic Leukemia (CMMOL)
C3178 (NCI Thesaurus)
C0023480 (UMLS 2011AA)
C0023480 (UMLS 2011AA)
CL Item
Acute Myeloid Leukemia (AML-TLD)
C3171 (NCI Thesaurus)
C0023467 (UMLS 2011AA)
C0023467 (UMLS 2011AA)
Item
I agree biopsies may be done to obtain research specimens.
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C15189 (NCI Thesaurus Property)
C0005558 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C0027361 (UMLS 2011AA ObjectClass)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C15189 (NCI Thesaurus Property)
C0005558 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
C1272460 (UMLS 2011AA)
Item
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C15207 (NCI Thesaurus Property)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0027361 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C15207 (NCI Thesaurus Property)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
I agree to provide additional specimens for research
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25168 (NCI Thesaurus Property)
C0040288 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0027361 (UMLS 2011AA ObjectClass)
C25168 (NCI Thesaurus Property)
C0040288 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
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)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C15206 (NCI Thesaurus Property)
C0008972 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C15206 (NCI Thesaurus Property)
C0008972 (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 about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Item
Someone from this institution may contact me in the future to ask me to take part in more research.
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C25406 (NCI Thesaurus Property)
C1524062 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C15319 (NCI Thesaurus Property)
C25406 (NCI Thesaurus Property)
C1524062 (UMLS 2011AA Property)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Code List
Someone from this institution may contact me in the future to ask me to take part in more research.
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CytogeneticsLaboratoryIdentifierName
Item
Name of local cytogenetics lab
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16487 (NCI Thesaurus ObjectClass)
C0010802 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16487 (NCI Thesaurus ObjectClass)
C0010802 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
CytogeneticsLaboratoryCommunicationContactTelephoneNumber
Item
Phone number
text
C16487 (NCI Thesaurus ObjectClass)
C0010802 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C47954 (NCI Thesaurus Property)
C1705415 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0010802 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C47954 (NCI Thesaurus Property)
C1705415 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Item
Patient's Race
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)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
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)
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)
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)
C1513907 (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)
C0078988 (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)
C1515945 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
Item Group
Patient Demographics / Pre-treatment Characteristics
Item
Patient's Sex
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C28421 (NCI Thesaurus Property)
C1522384 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ValueDomain)
C0030705 (UMLS 2011AA ValueDomain)
C28421 (NCI Thesaurus ValueDomain)
C1522384 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C28421 (NCI Thesaurus Property)
C1522384 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ValueDomain)
C0030705 (UMLS 2011AA ValueDomain)
C28421 (NCI Thesaurus ValueDomain)
C1522384 (UMLS 2011AA ValueDomain)
CL Item
Male (M)
C20197 (NCI Thesaurus)
C0024554 (UMLS 2011AA)
C0024554 (UMLS 2011AA)
CL Item
Female (F)
C16576 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
C0015780 (UMLS 2011AA)
PatientBirthDate
Item
Birthdate (mm/yy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
AddressPostalCodeIdentifier
Item
ZIP Code
text
C25407 (NCI Thesaurus ObjectClass)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C1442065 (UMLS 2011AA ValueDomain)
C25621 (NCI Thesaurus ValueDomain)
C1514254 (UMLS 2011AA ValueDomain)
C1442065 (UMLS 2011AA ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
C25407 (NCI Thesaurus ValueDomain)
C1442065 (UMLS 2011AA ValueDomain)
C25621 (NCI Thesaurus ValueDomain)
C1514254 (UMLS 2011AA ValueDomain)
Item
Patient Ethnicity
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)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C16564 (NCI Thesaurus Property)
C0015031 (UMLS 2011AA Property)
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)
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)
C1518424 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
Item
Patient's simplified disease code
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C16112 (NCI Thesaurus Property)
C1516637 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C16112 (NCI Thesaurus Property)
C1516637 (UMLS 2011AA Property)
CL Item
Acute Myeloid Leukemia (Acute Myeloid Leukemia, NOS)
C3171 (NCI Thesaurus)
C0023467 (UMLS 2011AA)
C0023467 (UMLS 2011AA)
CL Item
Chronic Myelomonocytic Leukemia (Chronic Myelomonocytic Leukemia)
C3178 (NCI Thesaurus)
C0023480 (UMLS 2011AA)
C0023480 (UMLS 2011AA)
CL Item
Mds (Myelodysplastic syndrome, NOS)
C3247 (NCI Thesaurus)
C0026986 (UMLS 2011AA)
C0026986 (UMLS 2011AA)
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)
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)
PatientSSNNumber
Item
Patient Social Security Number
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)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25686 (NCI Thesaurus Property)
C1301821 (UMLS 2011AA Property)
Item
Method of payment (check one)
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)
C25541 (NCI Thesaurus Property)
C1512888 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS 2011AA Property)
C25541 (NCI Thesaurus Property)
C1512888 (UMLS 2011AA Property)
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
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
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
AttendingPhysicianIdentifierIndividualsName
Item
Attending Physician
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL317115 (NCI Metathesaurus ObjectClass)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL317115 (NCI Metathesaurus ObjectClass)
InstitutionContactPersonName
Item
Institution contact
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
ProtocolRegistrarName
Item
Registrar
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25357 (NCI Thesaurus ObjectClass)
C0557514 (UMLS 2011AA ObjectClass)
Item
Country of residence
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)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25407 (NCI Thesaurus Property)
C1442065 (UMLS 2011AA Property)
CL Item
Ascension Island (AC)
CL Item
Andorra (AD)
C16289 (NCI Thesaurus)
C0002838 (UMLS 2011AA)
C0002838 (UMLS 2011AA)
CL Item
United Arab Emirates (AE)
C17232 (NCI Thesaurus)
C0041698 (UMLS 2011AA)
C0041698 (UMLS 2011AA)
CL Item
Afghanistan (AF)
C16267 (NCI Thesaurus)
C0001732 (UMLS 2011AA)
C0001732 (UMLS 2011AA)
CL Item
Antigua And Barbuda (AG)
C16303 (NCI Thesaurus)
C0003354 (UMLS 2011AA)
C0003354 (UMLS 2011AA)
CL Item
Anguilla (AI)
C20133 (NCI Thesaurus)
C0003353 (UMLS 2011AA)
C0003353 (UMLS 2011AA)
CL Item
Albania (AL)
CL Item
Armenia (AM)
C16306 (NCI Thesaurus)
C0003798 (UMLS 2011AA)
C0003798 (UMLS 2011AA)
CL Item
Netherland Antilles (AN)
CL Item
Angola (AO)
C16292 (NCI Thesaurus)
C0003023 (UMLS 2011AA)
C0003023 (UMLS 2011AA)
CL Item
Antarctica (AQ)
C18007 (NCI Thesaurus)
C0454691 (UMLS 2011AA)
C0454691 (UMLS 2011AA)
CL Item
Argentina (AR)
C16305 (NCI Thesaurus)
C0003761 (UMLS 2011AA)
C0003761 (UMLS 2011AA)
CL Item
American Samoa (AS)
C17739 (NCI Thesaurus)
C0242536 (UMLS 2011AA)
C0242536 (UMLS 2011AA)
CL Item
Austria (AT)
C16312 (NCI Thesaurus)
C0004348 (UMLS 2011AA)
C0004348 (UMLS 2011AA)
CL Item
Australia (AU)
C16311 (NCI Thesaurus)
C0004340 (UMLS 2011AA)
C0004340 (UMLS 2011AA)
CL Item
Aruba (AW)
C17884 (NCI Thesaurus)
C0282379 (UMLS 2011AA)
C0282379 (UMLS 2011AA)
CL Item
Azerbaidjan (AZ)
CL Item
Bosnia-herzegovina (BA)
C16361 (NCI Thesaurus)
C0006036 (UMLS 2011AA)
C0006036 (UMLS 2011AA)
CL Item
Barbados (BB)
C16324 (NCI Thesaurus)
C0004739 (UMLS 2011AA)
C0004739 (UMLS 2011AA)
CL Item
Bangladesh (BD)
C16323 (NCI Thesaurus)
C0004732 (UMLS 2011AA)
C0004732 (UMLS 2011AA)
CL Item
Belgium (BE)
C16329 (NCI Thesaurus)
C0004950 (UMLS 2011AA)
C0004950 (UMLS 2011AA)
CL Item
Burkina Faso (BF)
C16369 (NCI Thesaurus)
C0006409 (UMLS 2011AA)
C0006409 (UMLS 2011AA)
CL Item
Bulgaria (BG)
C16368 (NCI Thesaurus)
C0006368 (UMLS 2011AA)
C0006368 (UMLS 2011AA)
CL Item
Bahrain (BH)
C16322 (NCI Thesaurus)
C0004684 (UMLS 2011AA)
C0004684 (UMLS 2011AA)
CL Item
Burundi (BI)
C16371 (NCI Thesaurus)
C0006448 (UMLS 2011AA)
C0006448 (UMLS 2011AA)
CL Item
Benin (BJ)
CL Item
Bermuda (BM)
C16334 (NCI Thesaurus)
C0005126 (UMLS 2011AA)
C0005126 (UMLS 2011AA)
CL Item
Brunei Darussalam (BN)
C16367 (NCI Thesaurus)
C0006320 (UMLS 2011AA)
C0006320 (UMLS 2011AA)
CL Item
Bolivia (BO)
C16359 (NCI Thesaurus)
C0005918 (UMLS 2011AA)
C0005918 (UMLS 2011AA)
CL Item
Brazil (BR)
C16364 (NCI Thesaurus)
C0006137 (UMLS 2011AA)
C0006137 (UMLS 2011AA)
CL Item
Bahamas (BS)
C16321 (NCI Thesaurus)
C0004683 (UMLS 2011AA)
C0004683 (UMLS 2011AA)
CL Item
Bhutan (BT)
C16336 (NCI Thesaurus)
C0005341 (UMLS 2011AA)
C0005341 (UMLS 2011AA)
CL Item
Bouvet Island (BV)
C20104 (NCI Thesaurus)
C1511278 (UMLS 2011AA)
C1511278 (UMLS 2011AA)
CL Item
Botswana (BW)
C16363 (NCI Thesaurus)
C0006041 (UMLS 2011AA)
C0006041 (UMLS 2011AA)
CL Item
Belarus (BY)
C16372 (NCI Thesaurus)
C0006539 (UMLS 2011AA)
C0006539 (UMLS 2011AA)
CL Item
Belize (BZ)
C16331 (NCI Thesaurus)
C0004952 (UMLS 2011AA)
C0004952 (UMLS 2011AA)
CL Item
Canada (CA)
C16380 (NCI Thesaurus)
C0006823 (UMLS 2011AA)
C0006823 (UMLS 2011AA)
CL Item
Cocos Isl. (CC)
CL Item
Rep. Dem. Congo (CD)
CL Item
Central African Rep. (CF)
CL Item
Congo (CG)
C16467 (NCI Thesaurus)
C0009738 (UMLS 2011AA)
C0009738 (UMLS 2011AA)
CL Item
Switzerland (CH)
C17181 (NCI Thesaurus)
C0039021 (UMLS 2011AA)
C0039021 (UMLS 2011AA)
CL Item
Ivory Coast (CI)
CL Item
Cook Islands (CK)
C16469 (NCI Thesaurus)
C0009956 (UMLS 2011AA)
C0009956 (UMLS 2011AA)
CL Item
Chile (CL)
CL Item
Cameroon (CM)
C16379 (NCI Thesaurus)
C0006802 (UMLS 2011AA)
C0006802 (UMLS 2011AA)
CL Item
China (CN)
C16428 (NCI Thesaurus)
C0008115 (UMLS 2011AA)
C0008115 (UMLS 2011AA)
CL Item
Colombia (CO)
C16449 (NCI Thesaurus)
C0009367 (UMLS 2011AA)
C0009367 (UMLS 2011AA)
CL Item
Costa Rica (CR)
C16470 (NCI Thesaurus)
C0010182 (UMLS 2011AA)
C0010182 (UMLS 2011AA)
CL Item
Cuba (CU)
C16477 (NCI Thesaurus)
C0010435 (UMLS 2011AA)
C0010435 (UMLS 2011AA)
CL Item
Cape Verde (CV)
C16382 (NCI Thesaurus)
C0006893 (UMLS 2011AA)
C0006893 (UMLS 2011AA)
CL Item
Christmas Island (CX)
C44482 (NCI Thesaurus)
C0006888 (UMLS 2011AA)
C0006888 (UMLS 2011AA)
CL Item
Cyprus (CY)
C16480 (NCI Thesaurus)
C0010622 (UMLS 2011AA)
C0010622 (UMLS 2011AA)
CL Item
Czech Republic (CZ)
C17668 (NCI Thesaurus)
C0206578 (UMLS 2011AA)
C0206578 (UMLS 2011AA)
CL Item
Germany (DE)
CL Item
Djibouti (DJ)
CL Item
Denmark (DK)
CL Item
Dominica (DM)
CL Item
Dominican Republic (DO)
CL Item
Algeria (DZ)
CL Item
Ecuador (EC)
CL Item
Estonia (EE)
CL Item
Egypt (EG)
CL Item
Western Sahara (EH)
CL Item
Eritrea (ER)
CL Item
Spain (ES)
CL Item
Ethiopia (ET)
CL Item
Finland (FI)
CL Item
Fiji (FJ)
CL Item
Falkland Isl. (FK)
CL Item
Micronesia (FM)
CL Item
Faroe Islands (FO)
CL Item
France (FR)
CL Item
France (european Ter.) (FX)
CL Item
Gabon (GA)
CL Item
Great Britain (GB)
CL Item
Grenada (GD)
CL Item
Georgia (GE)
CL Item
Guiana (fr.) (GF)
CL Item
Guernsey (GG)
CL Item
Ghana (GH)
CL Item
Gibraltar (GI)
CL Item
Greenland (GL)
CL Item
Gambia (GM)
CL Item
Guinea (GN)
CL Item
Guadeloupe (fr.) (GP)
CL Item
Equatorial Guinea (GQ)
CL Item
Greece (GR)
CL Item
South Georgia And South Sandwich Islands (GS)
CL Item
Guatemala (GT)
CL Item
Guam (us) (GU)
CL Item
Guinea Bissau (GW)
CL Item
Guyana (GY)
CL Item
Hong Kong (HK)
CL Item
Heard & Mcdonald Isl. (HM)
CL Item
Honduras (HN)
C16694 (NCI Thesaurus)
C0019905 (UMLS 2011AA)
C0019905 (UMLS 2011AA)
CL Item
Croatia (HR)
C16474 (NCI Thesaurus)
C0010343 (UMLS 2011AA)
C0010343 (UMLS 2011AA)
CL Item
Haiti (HT)
C16660 (NCI Thesaurus)
C0018510 (UMLS 2011AA)
C0018510 (UMLS 2011AA)
CL Item
Hungary (HU)
C16699 (NCI Thesaurus)
C0020174 (UMLS 2011AA)
C0020174 (UMLS 2011AA)
CL Item
Indonesia (ID)
C16728 (NCI Thesaurus)
C0021247 (UMLS 2011AA)
C0021247 (UMLS 2011AA)
CL Item
Ireland (IE)
C16757 (NCI Thesaurus)
C0022067 (UMLS 2011AA)
C0022067 (UMLS 2011AA)
CL Item
Israel (IL)
C16760 (NCI Thesaurus)
C0022271 (UMLS 2011AA)
C0022271 (UMLS 2011AA)
CL Item
Isle Of Man (IM)
C0022132 (NCI Metathesaurus)
CL Item
India (IN)
C16727 (NCI Thesaurus)
C0021201 (UMLS 2011AA)
C0021201 (UMLS 2011AA)
CL Item
British Indian O. Ter. (IO)
CL Item
Iraq (IQ)
C16756 (NCI Thesaurus)
C0022066 (UMLS 2011AA)
C0022066 (UMLS 2011AA)
CL Item
Iran (IR)
C16755 (NCI Thesaurus)
C0022065 (UMLS 2011AA)
C0022065 (UMLS 2011AA)
CL Item
Iceland (IS)
C16704 (NCI Thesaurus)
C0020750 (UMLS 2011AA)
C0020750 (UMLS 2011AA)
CL Item
Italy (IT)
C16761 (NCI Thesaurus)
C0022277 (UMLS 2011AA)
C0022277 (UMLS 2011AA)
CL Item
Jersey (JE)
CL Item
Jamaica (JM)
C16763 (NCI Thesaurus)
C0022337 (UMLS 2011AA)
C0022337 (UMLS 2011AA)
CL Item
Jordan (JO)
C16765 (NCI Thesaurus)
C0022418 (UMLS 2011AA)
C0022418 (UMLS 2011AA)
CL Item
Japan (JP)
C16764 (NCI Thesaurus)
C0022341 (UMLS 2011AA)
C0022341 (UMLS 2011AA)
CL Item
Kenya (KE)
C16769 (NCI Thesaurus)
C0022558 (UMLS 2011AA)
C0022558 (UMLS 2011AA)
CL Item
Kyrgyz Republic (KG)
CL Item
Cambodia (KH)
C16378 (NCI Thesaurus)
C0006797 (UMLS 2011AA)
C0006797 (UMLS 2011AA)
CL Item
Kiribati (KI)
C16639 (NCI Thesaurus)
C0017550 (UMLS 2011AA)
C0017550 (UMLS 2011AA)
CL Item
Comoros (KM)
C16458 (NCI Thesaurus)
C0009490 (UMLS 2011AA)
C0009490 (UMLS 2011AA)
CL Item
St. Kitts Nevis Anguilla (KN)
CL Item
Korea (north) (KP)
CL Item
Korea (south) (KR)
CL Item
Kuwait (KW)
C16775 (NCI Thesaurus)
C0022804 (UMLS 2011AA)
C0022804 (UMLS 2011AA)
CL Item
Cayman Islands (KY)
C16391 (NCI Thesaurus)
C0007481 (UMLS 2011AA)
C0007481 (UMLS 2011AA)
CL Item
Kazakstan (KZ)
CL Item
Laos (LA)
CL Item
Lebanon (LB)
C16784 (NCI Thesaurus)
C0023190 (UMLS 2011AA)
C0023190 (UMLS 2011AA)
CL Item
Saint Lucia (LC)
C17113 (NCI Thesaurus)
C0036056 (UMLS 2011AA)
C0036056 (UMLS 2011AA)
CL Item
Liechtenstein (LI)
C16794 (NCI Thesaurus)
C0023668 (UMLS 2011AA)
C0023668 (UMLS 2011AA)
CL Item
Sri Lanka (LK)
C17163 (NCI Thesaurus)
C0038088 (UMLS 2011AA)
C0038088 (UMLS 2011AA)
CL Item
Liberia (LR)
C16791 (NCI Thesaurus)
C0023617 (UMLS 2011AA)
C0023617 (UMLS 2011AA)
CL Item
Lesotho (LS)
CL Item
Lithuania (LT)
C16799 (NCI Thesaurus)
C0023879 (UMLS 2011AA)
C0023879 (UMLS 2011AA)
CL Item
Luxembourg (LU)
C16803 (NCI Thesaurus)
C0024176 (UMLS 2011AA)
C0024176 (UMLS 2011AA)
CL Item
Latvia (LV)
C16783 (NCI Thesaurus)
C0023128 (UMLS 2011AA)
C0023128 (UMLS 2011AA)
CL Item
Libya (LY)
CL Item
Morocco (MA)
C16878 (NCI Thesaurus)
C0026544 (UMLS 2011AA)
C0026544 (UMLS 2011AA)
CL Item
Monaco (MC)
C16874 (NCI Thesaurus)
C0026405 (UMLS 2011AA)
C0026405 (UMLS 2011AA)
CL Item
Moldova (MD)
C16871 (NCI Thesaurus)
C0026374 (UMLS 2011AA)
C0026374 (UMLS 2011AA)
CL Item
Madagascar (MG)
C16808 (NCI Thesaurus)
C0024443 (UMLS 2011AA)
C0024443 (UMLS 2011AA)
CL Item
Marshall Islands (MH)
C16822 (NCI Thesaurus)
C0024851 (UMLS 2011AA)
C0024851 (UMLS 2011AA)
CL Item
Macedonia (MK)
C0700290 (NCI Metathesaurus)
CL Item
Mali (ML)
C16816 (NCI Thesaurus)
C0024581 (UMLS 2011AA)
C0024581 (UMLS 2011AA)
CL Item
Myanmar (MM)
C16370 (NCI Thesaurus)
C0006416 (UMLS 2011AA)
C0006416 (UMLS 2011AA)
CL Item
Mongolia (MN)
C16875 (NCI Thesaurus)
C0026410 (UMLS 2011AA)
C0026410 (UMLS 2011AA)
CL Item
Macau (MO)
C16807 (NCI Thesaurus)
C0024403 (UMLS 2011AA)
C0024403 (UMLS 2011AA)
CL Item
Northern Mariana Isl. (MP)
CL Item
Martinique (fr.) (MQ)
CL Item
Mauritania (MR)
C16826 (NCI Thesaurus)
C0024943 (UMLS 2011AA)
C0024943 (UMLS 2011AA)
CL Item
Montserrat (MS)
C16876 (NCI Thesaurus)
C0026514 (UMLS 2011AA)
C0026514 (UMLS 2011AA)
CL Item
Malta (MT)
C16817 (NCI Thesaurus)
C0024653 (UMLS 2011AA)
C0024653 (UMLS 2011AA)
CL Item
Mauritius (MU)
C16827 (NCI Thesaurus)
C0024944 (UMLS 2011AA)
C0024944 (UMLS 2011AA)
CL Item
Maldives (MV)
C16815 (NCI Thesaurus)
C0024553 (UMLS 2011AA)
C0024553 (UMLS 2011AA)
CL Item
Malawi (MW)
C16813 (NCI Thesaurus)
C0024548 (UMLS 2011AA)
C0024548 (UMLS 2011AA)
CL Item
Mexico (MX)
C16850 (NCI Thesaurus)
C0025885 (UMLS 2011AA)
C0025885 (UMLS 2011AA)
CL Item
Malaysia (MY)
C16814 (NCI Thesaurus)
C0024552 (UMLS 2011AA)
C0024552 (UMLS 2011AA)
CL Item
Mozambique (MZ)
C16882 (NCI Thesaurus)
C0026655 (UMLS 2011AA)
C0026655 (UMLS 2011AA)
CL Item
Namibia (NA)
C16891 (NCI Thesaurus)
C0027366 (UMLS 2011AA)
C0027366 (UMLS 2011AA)
CL Item
New Caledonia (fr.) (NC)
CL Item
Niger (NE)
C16916 (NCI Thesaurus)
C0028074 (UMLS 2011AA)
C0028074 (UMLS 2011AA)
CL Item
Norfolk Island (NF)
C16919 (NCI Thesaurus)
C0028366 (UMLS 2011AA)
C0028366 (UMLS 2011AA)
CL Item
Nigeria (NG)
C16917 (NCI Thesaurus)
C0028075 (UMLS 2011AA)
C0028075 (UMLS 2011AA)
CL Item
Nicaragua (NI)
C16915 (NCI Thesaurus)
C0028002 (UMLS 2011AA)
C0028002 (UMLS 2011AA)
CL Item
Netherlands (NL)
C16903 (NCI Thesaurus)
C0027778 (UMLS 2011AA)
C0027778 (UMLS 2011AA)
CL Item
Norway (NO)
C16920 (NCI Thesaurus)
C0028423 (UMLS 2011AA)
C0028423 (UMLS 2011AA)
CL Item
Nepal (NP)
C16901 (NCI Thesaurus)
C0027689 (UMLS 2011AA)
C0027689 (UMLS 2011AA)
CL Item
Nauru (NR)
C16896 (NCI Thesaurus)
C0027496 (UMLS 2011AA)
C0027496 (UMLS 2011AA)
CL Item
Niue (NU)
C16918 (NCI Thesaurus)
C0028219 (UMLS 2011AA)
C0028219 (UMLS 2011AA)
CL Item
New Zealand (NZ)
C16914 (NCI Thesaurus)
C0027978 (UMLS 2011AA)
C0027978 (UMLS 2011AA)
CL Item
Oman (OM)
C16933 (NCI Thesaurus)
C0028971 (UMLS 2011AA)
C0028971 (UMLS 2011AA)
CL Item
Other (Other)
CL Item
Panama (PA)
C16951 (NCI Thesaurus)
C0030266 (UMLS 2011AA)
C0030266 (UMLS 2011AA)
CL Item
Peru (PE)
C16972 (NCI Thesaurus)
C0031238 (UMLS 2011AA)
C0031238 (UMLS 2011AA)
CL Item
Polynesia (fr.) (PF)
CL Item
Papua New Guinea (PG)
C16952 (NCI Thesaurus)
C0030375 (UMLS 2011AA)
C0030375 (UMLS 2011AA)
CL Item
Philippines (PH)
CL Item
Pakistan (PK)
C16949 (NCI Thesaurus)
C0030211 (UMLS 2011AA)
C0030211 (UMLS 2011AA)
CL Item
Poland (PL)
C17002 (NCI Thesaurus)
C0032356 (UMLS 2011AA)
C0032356 (UMLS 2011AA)
CL Item
St. Pierre & Miquelon (PM)
CL Item
Pitcairn (PN)
C16993 (NCI Thesaurus)
C0031995 (UMLS 2011AA)
C0031995 (UMLS 2011AA)
CL Item
Puerto Rico (PR)
C17043 (NCI Thesaurus)
C0034044 (UMLS 2011AA)
C0034044 (UMLS 2011AA)
CL Item
Portugal (PT)
C17006 (NCI Thesaurus)
C0032729 (UMLS 2011AA)
C0032729 (UMLS 2011AA)
CL Item
Palau (PW)
C17733 (NCI Thesaurus)
C0242397 (UMLS 2011AA)
C0242397 (UMLS 2011AA)
CL Item
Paraguay (PY)
C16953 (NCI Thesaurus)
C0030428 (UMLS 2011AA)
C0030428 (UMLS 2011AA)
CL Item
Qatar (QA)
C17045 (NCI Thesaurus)
C0034366 (UMLS 2011AA)
C0034366 (UMLS 2011AA)
CL Item
Reunion (fr.) (RE)
CL Item
Romania (RO)
C17108 (NCI Thesaurus)
C0035826 (UMLS 2011AA)
C0035826 (UMLS 2011AA)
CL Item
Russian Federation (RU)
CL Item
Rwanda (RW)
C17112 (NCI Thesaurus)
C0035978 (UMLS 2011AA)
C0035978 (UMLS 2011AA)
CL Item
Saudi Arabia (SA)
C17117 (NCI Thesaurus)
C0036243 (UMLS 2011AA)
C0036243 (UMLS 2011AA)
CL Item
Solomon Islands (SB)
C17148 (NCI Thesaurus)
C0037623 (UMLS 2011AA)
C0037623 (UMLS 2011AA)
CL Item
Seychelles (SC)
C17129 (NCI Thesaurus)
C0036919 (UMLS 2011AA)
C0036919 (UMLS 2011AA)
CL Item
Sudan (SD)
C17170 (NCI Thesaurus)
C0038642 (UMLS 2011AA)
C0038642 (UMLS 2011AA)
CL Item
Sweden (SE)
C17180 (NCI Thesaurus)
C0038995 (UMLS 2011AA)
C0038995 (UMLS 2011AA)
CL Item
Singapore (SG)
C17134 (NCI Thesaurus)
C0037173 (UMLS 2011AA)
C0037173 (UMLS 2011AA)
CL Item
St. Helena (SH)
CL Item
Slovenia (SI)
C17138 (NCI Thesaurus)
C0037334 (UMLS 2011AA)
C0037334 (UMLS 2011AA)
CL Item
Svalbard & Jan Mayen Isl. (SJ)
CL Item
Slovakia (SK)
C17669 (NCI Thesaurus)
C0206579 (UMLS 2011AA)
C0206579 (UMLS 2011AA)
CL Item
Sierra Leone (SL)
C17130 (NCI Thesaurus)
C0037063 (UMLS 2011AA)
C0037063 (UMLS 2011AA)
CL Item
San Marino (SM)
C17115 (NCI Thesaurus)
C0036154 (UMLS 2011AA)
C0036154 (UMLS 2011AA)
CL Item
Senegal (SN)
C17121 (NCI Thesaurus)
C0036644 (UMLS 2011AA)
C0036644 (UMLS 2011AA)
CL Item
Somalia (SO)
C17149 (NCI Thesaurus)
C0037640 (UMLS 2011AA)
C0037640 (UMLS 2011AA)
CL Item
Suriname (SR)
C17175 (NCI Thesaurus)
C0038944 (UMLS 2011AA)
C0038944 (UMLS 2011AA)
CL Item
St. Tome And Principe (ST)
CL Item
Soviet Union (SU)
CL Item
El Salvador (SV)
C16532 (NCI Thesaurus)
C0013754 (UMLS 2011AA)
C0013754 (UMLS 2011AA)
CL Item
Syria (SY)
C17182 (NCI Thesaurus)
C0039138 (UMLS 2011AA)
C0039138 (UMLS 2011AA)
CL Item
Swaziland (SZ)
C17179 (NCI Thesaurus)
C0038983 (UMLS 2011AA)
C0038983 (UMLS 2011AA)
CL Item
Turks & Caicos Islands (TC)
CL Item
Chad (TD)
C16412 (NCI Thesaurus)
C0007928 (UMLS 2011AA)
C0007928 (UMLS 2011AA)
CL Item
French Southern Terr. (TF)
CL Item
Togo (TG)
C17202 (NCI Thesaurus)
C0040363 (UMLS 2011AA)
C0040363 (UMLS 2011AA)
CL Item
Thailand (TH)
C17192 (NCI Thesaurus)
C0039725 (UMLS 2011AA)
C0039725 (UMLS 2011AA)
CL Item
Tadjikistan (TJ)
CL Item
Tokelau (TK)
C17704 (NCI Thesaurus)
C0220928 (UMLS 2011AA)
C0220928 (UMLS 2011AA)
CL Item
Turkmenistan (TM)
C17223 (NCI Thesaurus)
C0041403 (UMLS 2011AA)
C0041403 (UMLS 2011AA)
CL Item
Tunisia (TN)
C17221 (NCI Thesaurus)
C0041388 (UMLS 2011AA)
C0041388 (UMLS 2011AA)
CL Item
Tonga (TO)
CL Item
East Timor (TP)
C17200 (NCI Thesaurus)
C1452561 (UMLS 2011AA)
C1452561 (UMLS 2011AA)
CL Item
Turkey (TR)
C17222 (NCI Thesaurus)
C0041400 (UMLS 2011AA)
C0041400 (UMLS 2011AA)
CL Item
Trinidad & Tobago (TT)
CL Item
Tuvalu (TV)
C17225 (NCI Thesaurus)
C0041413 (UMLS 2011AA)
C0041413 (UMLS 2011AA)
CL Item
Taiwan (TW)
C17184 (NCI Thesaurus)
C0039260 (UMLS 2011AA)
C0039260 (UMLS 2011AA)
CL Item
Tanzania (TZ)
C17185 (NCI Thesaurus)
C0039298 (UMLS 2011AA)
C0039298 (UMLS 2011AA)
CL Item
Ukraine (UA)
C17229 (NCI Thesaurus)
C0041580 (UMLS 2011AA)
C0041580 (UMLS 2011AA)
CL Item
Uganda (UG)
C17228 (NCI Thesaurus)
C0041573 (UMLS 2011AA)
C0041573 (UMLS 2011AA)
CL Item
United Kingdom (UK)
C17233 (NCI Thesaurus)
C0041700 (UMLS 2011AA)
C0041700 (UMLS 2011AA)
CL Item
Us Minor Outlying Isl. (UM)
CL Item
Usa (US)
CL Item
Uruguay (UY)
C17244 (NCI Thesaurus)
C0042113 (UMLS 2011AA)
C0042113 (UMLS 2011AA)
CL Item
Uzbekistan (UZ)
C17246 (NCI Thesaurus)
C0042177 (UMLS 2011AA)
C0042177 (UMLS 2011AA)
CL Item
Vatican City State (VA)
CL Item
St. Vincent & Grenadines (VC)
CL Item
Venezuela (VE)
C17250 (NCI Thesaurus)
C0042469 (UMLS 2011AA)
C0042469 (UMLS 2011AA)
CL Item
Virgin Islands (brit) (VG)
CL Item
Virgin Islands (us) (VI)
CL Item
Vietnam (VN)
C17252 (NCI Thesaurus)
C0042658 (UMLS 2011AA)
C0042658 (UMLS 2011AA)
CL Item
Vanuatu (VU)
C17247 (NCI Thesaurus)
C0042321 (UMLS 2011AA)
C0042321 (UMLS 2011AA)
CL Item
Wallis & Futuna Islands (WF)
CL Item
Western Samoa (WS)
CL Item
Yemen (YE)
C17264 (NCI Thesaurus)
C0043402 (UMLS 2011AA)
C0043402 (UMLS 2011AA)
CL Item
Mayotte (YT)
C16828 (NCI Thesaurus)
C0024974 (UMLS 2011AA)
C0024974 (UMLS 2011AA)
CL Item
Yugoslavia (YU)
CL Item
South Africa (ZA)
CL Item
Zambia (ZM)
C17267 (NCI Thesaurus)
C0043445 (UMLS 2011AA)
C0043445 (UMLS 2011AA)
CL Item
Dem. Rep. Of Congo (ZR)
CL Item
Zimbabwe (ZW)
C17268 (NCI Thesaurus)
C0043476 (UMLS 2011AA)
C0043476 (UMLS 2011AA)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item Group
I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct
TreatingPhysicianSignatureText
Item
Signature of treating physician
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C51883 (NCI Thesaurus ObjectClass)
C1710470 (UMLS 2011AA ObjectClass)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C51883 (NCI Thesaurus ObjectClass)
C1710470 (UMLS 2011AA ObjectClass)
TreatingPhysicianSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C51883 (NCI Thesaurus ObjectClass)
C1710470 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C51883 (NCI Thesaurus ObjectClass)
C1710470 (UMLS 2011AA ObjectClass)
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