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ID

7022

Description

North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form Radiation Therapy or Radiation Therapy and Temozolomide or Temozolomide Alone in Treating Patients With Newly Diagnosed Anaplastic Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C096CEC-6180-47DB-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C096CEC-6180-47DB-E044-0003BA3F9857

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Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
Uploaded on

January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Brain and Central Nervous System Tumors NCT00887146 Registration - North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form - 2745776v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form
      1. No Instruction available.
    Header
    Description

    Header

    Protocol Number
    Description

    Protocol ID NCCTG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1518419
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25581
    Patient ID
    Description

    PatientNorthCentralCancerTreatmentGroupIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25581
    UMLS 2011AA Property-2
    C1518419
    Patient Initials (L F M)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution Number
    Description

    Institution Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Institution
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Are data amended (If yes, highlight amended areas)
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Preregistration Screening Failure
    Description

    Preregistration Screening Failure

    Date aware of preregistration screening failure (mm/dd/yyyy)
    Description

    PriorRegistrationScreeningPatientClinicalTrialIneligibilityDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C48261
    UMLS 2011AA ObjectClass-2
    C1710032
    NCI Thesaurus ObjectClass-3
    C25646
    UMLS 2011AA ObjectClass-3
    C1514821
    NCI Thesaurus ObjectClass-4
    C25629
    UMLS 2011AA ObjectClass-4
    C0332152
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property-2
    C40412
    UMLS 2011AA Property
    C1512714
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Primary reason screening failed (check one)
    Description

    PriorRegistrationScreeningPatientClinicalTrialIneligibilityReason

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C48261
    UMLS 2011AA ObjectClass-2
    C1710032
    NCI Thesaurus ObjectClass-3
    C25646
    UMLS 2011AA ObjectClass-3
    C1514821
    NCI Thesaurus ObjectClass-4
    C25629
    UMLS 2011AA ObjectClass-4
    C0332152
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property-2
    C40412
    UMLS 2011AA Property
    C1512714
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    Other, specify
    Description

    PriorRegistrationScreeningPatientClinicalTrialIneligibilitySpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C48261
    UMLS 2011AA ObjectClass-2
    C1710032
    NCI Thesaurus ObjectClass-3
    C25646
    UMLS 2011AA ObjectClass-3
    C1514821
    NCI Thesaurus ObjectClass-4
    C25629
    UMLS 2011AA ObjectClass-4
    C0332152
    NCI Thesaurus Property
    C15207
    NCI Thesaurus Property-2
    C40412
    UMLS 2011AA Property
    C1512714
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Protocol ID NCCTG
    Item
    Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1518419 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25581 (NCI Thesaurus Property-2)
    PatientNorthCentralCancerTreatmentGroupIdentifierNumber
    Item
    Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25581 (NCI Thesaurus Property-2)
    C1518419 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials (L F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Institution Name
    Item
    Institution
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Data amended
    Item
    Are data amended (If yes, highlight amended areas)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Preregistration Screening Failure
    PriorRegistrationScreeningPatientClinicalTrialIneligibilityDate
    Item
    Date aware of preregistration screening failure (mm/dd/yyyy)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48261 (NCI Thesaurus ObjectClass-2)
    C1710032 (UMLS 2011AA ObjectClass-2)
    C25646 (NCI Thesaurus ObjectClass-3)
    C1514821 (UMLS 2011AA ObjectClass-3)
    C25629 (NCI Thesaurus ObjectClass-4)
    C0332152 (UMLS 2011AA ObjectClass-4)
    C15207 (NCI Thesaurus Property)
    C40412 (NCI Thesaurus Property-2)
    C1512714 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Primary reason screening failed (check one)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48261 (NCI Thesaurus ObjectClass-2)
    C1710032 (UMLS 2011AA ObjectClass-2)
    C25646 (NCI Thesaurus ObjectClass-3)
    C1514821 (UMLS 2011AA ObjectClass-3)
    C25629 (NCI Thesaurus ObjectClass-4)
    C0332152 (UMLS 2011AA ObjectClass-4)
    C15207 (NCI Thesaurus Property)
    C40412 (NCI Thesaurus Property-2)
    C1512714 (UMLS 2011AA Property)
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Primary reason screening failed (check one)
    CL Item
    Investigator Decision (Investigator decision)
    CL Item
    Patient Decision (Patient decision)
    CL Item
    Did Not Meet Eligibility Criteria (Did not meet eligibility criteria)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PriorRegistrationScreeningPatientClinicalTrialIneligibilitySpecify
    Item
    Other, specify
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48261 (NCI Thesaurus ObjectClass-2)
    C1710032 (UMLS 2011AA ObjectClass-2)
    C25646 (NCI Thesaurus ObjectClass-3)
    C1514821 (UMLS 2011AA ObjectClass-3)
    C25629 (NCI Thesaurus ObjectClass-4)
    C0332152 (UMLS 2011AA ObjectClass-4)
    C15207 (NCI Thesaurus Property)
    C40412 (NCI Thesaurus Property-2)
    C1512714 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
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