Form Administration
IRB Approval Date
date
InformedConsentFormSignedDate
date
ConsentFormSignedEndDate
date
Treatment Begin Date
date
PatientRegistrationDate
date
PatientSignedDischargeMedicalRecordDate
date
Date Form Completed
date
Person Completing Form Last Name
text
Person Completing Form First Name
text
Person Completing Form Phone
text
ResponsiblePersonFaxNumber
text
Patient Demographics / Pre-treatment Characteristics
PatientName
text
Patient Birth Date
date
PatientGenderCategory
text
PatientRaceCategory
text
PatientEthnicGroupCategory
text
PatientSSNNumber
float
PatientAddressPostalCode
text
PatientAddressCountryName
text
Patient Height
float
Patient Weight
float
Body Surface Area
float
ECOG Performance Status
text
KarnofskyPerformanceStatusScore
text
PatientPaymentType
text
Certification Of Eligibility
PatientEligibilityIndicator
boolean
Protocol Design
StudyStratificationText
text
Protocol Treatment Arm
text
TreatmentAssignmentCode
text
AgentNSC/GPIIdentifierNumber
text
Agent
text
Medication Dose
float
Units
text
Drug Administration Route
text
Medication frequency
text
TherapeuticAgentsAdministeredScheduleText
text
Initial Patient Consent For Specimen Use
SpecimenResearchConsentRelatedInd-3
boolean
BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3
boolean
PatientContactConsentInd-3
boolean
SpecimenICFSignedDate
date