ID

7114

Description

North Central Cancer Treatment Group N0147 Preregistration Screening Failure Form Comparison of Combination Chemotherapy Regimens With or Without Cetuximab in Treating Patients Who Have Undergone Surgery For Stage III Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=57BB37FE-4136-38E6-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=57BB37FE-4136-38E6-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Colorectal Cancer NCT00079274 Registration - North Central Cancer Treatment Group N0147 Preregistration Screening Failure Form - 2787580v1.0

English

NOTE: If the patient is not proceeding to Registration/Randomization, the site must FAX this form to the NCCTG Operations Office, Attention: N0147 Quality Control Specialist (507-284-1902)

1 forms  
Header
Description

Header

Coordinating Group Protocol Number
Description

Protocol ID Coordinating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1711341
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Coordinating Group Code
Description

Coordinating Group Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C1711341
NCI Thesaurus ObjectClass
C17005
UMLS CUI-2
C0805701
NCI Thesaurus ObjectClass-2
C25462
NCI Thesaurus Property
C25364
Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986303
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C42774
Patient Study ID
Description

Patient Study ID

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Patient Medical Record Number
Description

Medical Record Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
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
Participating Group Code (Cooperative Group where credit will be applied)
Description

ParticipatingGroupIdentifierCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass-2
C17005
UMLS 2011AA ObjectClass-2
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution Name (treating location/performance site)
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
Back to the top of the page

Similar models

NOTE: If the patient is not proceeding to Registration/Randomization, the site must FAX this form to the NCCTG Operations Office, Attention: N0147 Quality Control Specialist (507-284-1902)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Protocol ID Coordinating Group
Item
Coordinating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1711341 (UMLS CUI-2)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Coordinating Group Code
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C1711341 (UMLS CUI-1)
C17005 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25462 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Protocol Title
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)
Patient Study ID
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Medical Record Number
Item
Patient Medical Record Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus 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)
ParticipatingGroupIdentifierCode
Item
Participating Group Code (Cooperative Group where credit will be applied)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C1257890 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Institution Name
Item
Institution Name (treating location/performance site)
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
Not Evaluable For Kras (Not evaluable for KRAS)
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)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial