Protocol Administration
IRB Approval Date
date
InformedConsentFormSignedDate
date
Treatment Begin Date
date
PatientSignedDischargeMedicalRecordDate
date
InstitutionContactPersonName
text
Person Completing Form Phone
text
ResponsiblePersonFaxNumber
text
Patient Demographics/pre-treatment Characteristics
Patient Initials
text
Patient Birth Date
date
PatientPersonSocialSecurityNumber
text
Medical Record Number
text
PatientGenderCategory
text
PatientRaceCategory
text
PatientEthnicGroupCategory
text
Patient Demographics/pre-treatment Characteristics2
PatientAddressPostalCode
text
PatientAddressCountryName
text
Certification Of Eligibility And Protocol Design
PatientEligibilityIndicator
boolean
PatientQualityofLifeConsentInd-2
boolean
Initial Patient Consent For Specimen Use
SpecimenResearchConsentRelatedInd-3
boolean
BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3
text
PatientContactConsentInd-3
boolean
Registration Information
PatientRegistrationDate
date
Trial subject ID CALGB
text
Trial subject ID Participating Group
text
RegisteringPersonIdentifierSignatureName
text