ID

8669

Descrizione

A0 OPEN Form - 1005 Higher-Dose Radiation Therapy or Standard Radiation Therapy in Treating Patients With Early-Stage Breast Cancer That Was Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA9F360-A112-1EA4-E040-BB89AD432FA2

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA9F360-A112-1EA4-E040-BB89AD432FA2

Keywords

versioni (2)
  1. 18/12/14 18/12/14 - Martin Dugas
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT01349322 Demographic - A0 OPEN Form - 1005 - 3198937v1.0

    Inglese

    No Instruction available.

    1 moduli  
    1. StudyEvent: A0 OPEN Form - 1005
      1. No Instruction available.
    Module 1
    Descrizione

    Module 1

    Institutional person randomizing case
    Descrizione

    RandomizationPersonName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass-2
    C25196
    UMLS 2011AA ObjectClass-2
    C0034656
    Has the eligibility checklist been completed
    Descrizione

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C25171
    UMLS 2011AA ObjectClass
    C0013893
    NCI Thesaurus Property-2
    C49073
    UMLS 2011AA Property-2
    C1707357
    In the opinion of the investigator, is the patient eligible?
    Descrizione

    Eligibility for trial

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1302261
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25171
    Date Informed Consent Signed (mm/dd/yyyy)
    Descrizione

    InformedConsentFormSignedDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    First
    Descrizione

    Patient Initials First

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C0205435
    NCI Thesaurus Property
    C25536
    NCI Thesaurus Property-2
    C25509
    Middle
    Descrizione

    PatientMiddleInitialsName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    NCI Thesaurus Property-2
    C25569
    UMLS 2011AA Property-2
    C0444598
    Last
    Descrizione

    Patient Initials Last

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1517741
    NCI Thesaurus Property
    C25536
    NCI Thesaurus Property-2
    C25551
    Verifying physician
    Descrizione

    PhysicianPersonVerificationIdentifierName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass-2
    C25741
    UMLS 2011AA ObjectClass-2
    C0031831
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C45513
    UMLS 2011AA Property-2
    C1711411
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Patient ID
    Descrizione

    Patient Study ID

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Race
    Descrizione

    RegistrationRaceVerificationCategory

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C17049
    UMLS 2011AA Property
    C0034510
    NCI Thesaurus Property-2
    C45513
    UMLS 2011AA Property-2
    C1711411
    Any care at VA or military hospital
    Descrizione

    TherapeuticProcedureVeteransAdministrationMilitaryHospitalReceivedInd-3

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C49236
    UMLS 2011AA ObjectClass
    C0087111
    NCI Thesaurus Property
    C16696
    UMLS 2011AA Property
    C0019994
    NCI Thesaurus Property-2
    C25639
    UMLS 2011AA Property-2
    C1514756
    NCI Thesaurus Property-3
    C68638
    UMLS 2011AA Property-3
    C0026126
    NCI Thesaurus Property-4
    C17239
    UMLS 2011AA Property-4
    C0041735
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Calendar base date
    Descrizione

    TherapeuticProcedureCalendarGenerationDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C49236
    UMLS 2011AA ObjectClass
    C0087111
    NCI Thesaurus Property
    C19459
    UMLS 2011AA Property
    C1516147
    NCI Thesaurus Property-2
    C48151
    UMLS 2011AA Property-2
    C0079411
    Randomization Date
    Descrizione

    PatientRandomizationDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25196
    UMLS 2011AA Property
    C0034656
    Module 1
    Descrizione

    Module 1

    Have you obtained the patient's consent for her tissue to be kept for use in research to learn about, prevent, treat, or cure cancer?
    Descrizione

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C9305
    UMLS 2011AA Property
    C0006826
    NCI Thesaurus Property-3
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Have you obtained the patient's consent for her blood to be kept for use in research to learn about, prevent, treat, or cure cancer?
    Descrizione

    BloodSpecimenMalignantNeoplasmRelatedResearchConsentIndicator

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25648
    UMLS 2011AA Property
    C0439849
    NCI Thesaurus Property-3
    C9305
    UMLS 2011AA Property-2
    C0006826
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Have you obtained the patient's consent for her tissue to be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)?
    Descrizione

    BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12801
    UMLS 2011AA ObjectClass
    C0040300
    NCI Thesaurus ObjectClass-2
    C12434
    UMLS 2011AA ObjectClass-2
    C0229664
    NCI Thesaurus ObjectClass-3
    C19157
    UMLS 2011AA ObjectClass-3
    C0370003
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C15319
    NCI Thesaurus Property-3
    C2991
    UMLS 2011AA Property-2
    C0012634
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Have you obtained the patient's consent for her blood to be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)?
    Descrizione

    BloodSpecimenOtherDiseasesandDisordersResearchConsentInd-3

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C15319
    NCI Thesaurus Property-3
    C2991
    UMLS 2011AA Property-2
    C0012634
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Have you obtained the patient's consent to allow someone from this institution to contact her in the future to take part in more research?
    Descrizione

    Permission to contact Patient

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C1522577
    NCI Thesaurus Property
    C67527
    UMLS CUI-2
    C0521104
    NCI Thesaurus Property-2
    C25460
    NCI Thesaurus Property-3
    C16452
    NCI Thesaurus ValueDomain
    C38148
    Patient has consented to participate in the cosmesis study
    Descrizione

    PatientBreastReconstructionConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus Property-2
    C15354
    UMLS 2011AA Property-2
    C0085076
    If no, provide reason
    Descrizione

    PatientBreastReconstructionRefuseConsentReason

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C49161
    UMLS 2011AA Property
    C1705116
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus Property-3
    C15354
    UMLS 2011AA Property-3
    C0085076
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    Patient refused for other reason: specify
    Descrizione

    PatientBreastReconstructionRefuseConsentOtherSpecify

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C49161
    UMLS 2011AA Property
    C1705116
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus Property-3
    C15354
    UMLS 2011AA Property-3
    C0085076
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ValueDomain-2
    C17649
    UMLS 2011AA ValueDomain-2
    C0205394
    Other, specify
    Descrizione

    PatientBreastReconstructionRefuseConsentSpecify

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C49161
    UMLS 2011AA Property
    C1705116
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus Property-3
    C15354
    UMLS 2011AA Property-3
    C0085076
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Age
    Descrizione

    PatientFirstProtocolRegistrationAgeYearCount

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25320
    UMLS 2011AA Property
    C1507394
    NCI Thesaurus Property-2
    C25646
    UMLS 2011AA Property-2
    C1514821
    NCI Thesaurus Property-3
    C25509
    UMLS 2011AA Property-3
    C1279901
    NCI Thesaurus ValueDomain
    C29848
    UMLS 2011AA ValueDomain
    C0439234
    NCI Thesaurus ValueDomain-2
    C25463
    UMLS 2011AA ValueDomain-2
    C0750480
    Intention to receive chemotherapy
    Descrizione

    PatientChemotherapyIntentReceiveInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C15632
    UMLS 2011AA ObjectClass-2
    C0392920
    NCI Thesaurus Property
    C25639
    UMLS 2011AA Property
    C1514756
    NCI Thesaurus Property-2
    C25725
    UMLS 2011AA Property-2
    C1283828
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    ER Status
    Descrizione

    ERLevelTumorStatus

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C3262
    UMLS 2011AA ValueDomain
    C0027651
    NCI Thesaurus ObjectClass
    C17069
    UMLS 2011AA ObjectClass
    C0034804
    NCI Thesaurus ValueDomain-2
    C25688
    UMLS 2011AA ValueDomain-2
    C0449438
    NCI Thesaurus Property
    C25554
    UMLS 2011AA Property
    C0441889
    Histologic Grade
    Descrizione

    ClinicalStudyBreastCarcinomaHistologicGradeStratificationType

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C15206
    UMLS 2011AA ObjectClass
    C0008972
    NCI Thesaurus Property
    C4872
    UMLS 2011AA Property
    C0678222
    NCI Thesaurus Property-2
    C18000
    UMLS 2011AA Property-2
    C0919553
    NCI Thesaurus Property-3
    C25689
    UMLS 2011AA Property-3
    C1514983
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Patient
    Descrizione

    Patient

    Radiation Therapy Technique
    Descrizione

    RadiationTherapyTechniqueType

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C16847
    UMLS 2011AA Property
    C0449851
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
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    1 moduli
    1. StudyEvent: A0 OPEN Form - 1005
      1. No Instruction available.
    Name
    genere
    Description | Question | Decode (Coded Value)
    Tipo di dati
    Alias
    Item Group
    Module 1
    RandomizationPersonName
    Item
    Institutional person randomizing case
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25196 (NCI Thesaurus ObjectClass-2)
    C0034656 (UMLS 2011AA ObjectClass-2)
    EligibilityDeterminationChecklistCompleteEligibilityInd-2
    Item
    Has the eligibility checklist been completed
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus ObjectClass)
    C0013893 (UMLS 2011AA ObjectClass)
    C49073 (NCI Thesaurus Property-2)
    C1707357 (UMLS 2011AA Property-2)
    Eligibility for trial
    Item
    In the opinion of the investigator, is the patient eligible?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1302261 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25171 (NCI Thesaurus Property)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    Patient Initials First
    Item
    First
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C0205435 (UMLS CUI-2)
    C25536 (NCI Thesaurus Property)
    C25509 (NCI Thesaurus Property-2)
    PatientMiddleInitialsName
    Item
    Middle
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    C25569 (NCI Thesaurus Property-2)
    C0444598 (UMLS 2011AA Property-2)
    Patient Initials Last
    Item
    Last
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1517741 (UMLS CUI-2)
    C25536 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    PhysicianPersonVerificationIdentifierName
    Item
    Verifying physician
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25741 (NCI Thesaurus ObjectClass-2)
    C0031831 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C45513 (NCI Thesaurus Property-2)
    C1711411 (UMLS 2011AA Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    Patient Study ID
    Item
    Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item
    Race
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C17049 (NCI Thesaurus Property)
    C0034510 (UMLS 2011AA Property)
    C45513 (NCI Thesaurus Property-2)
    C1711411 (UMLS 2011AA Property-2)
    CL.3
    Code List
    Race
    CL Item
    American Indian Or Alaska Native (American Indian or Alaska Native)
    C41259 (NCI Thesaurus)
    C1515945 (UMLS 2011AA)
    CL Item
    Asian (Asian)
    C41260 (NCI Thesaurus)
    C0078988 (UMLS 2011AA)
    CL Item
    Black Or African American (Black or African American)
    C16352 (NCI Thesaurus)
    C0085756 (UMLS 2011AA)
    CL Item
    Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
    C41219 (NCI Thesaurus)
    C1513907 (UMLS 2011AA)
    CL Item
    White (White)
    C41261 (NCI Thesaurus)
    C0007457 (UMLS 2011AA)
    CL Item
    More Than One Race (More than one race)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Item
    Any care at VA or military hospital
    text
    C49236 (NCI Thesaurus ObjectClass)
    C0087111 (UMLS 2011AA ObjectClass)
    C16696 (NCI Thesaurus Property)
    C0019994 (UMLS 2011AA Property)
    C25639 (NCI Thesaurus Property-2)
    C1514756 (UMLS 2011AA Property-2)
    C68638 (NCI Thesaurus Property-3)
    C0026126 (UMLS 2011AA Property-3)
    C17239 (NCI Thesaurus Property-4)
    C0041735 (UMLS 2011AA Property-4)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Any care at VA or military hospital
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    TherapeuticProcedureCalendarGenerationDate
    Item
    Calendar base date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C49236 (NCI Thesaurus ObjectClass)
    C0087111 (UMLS 2011AA ObjectClass)
    C19459 (NCI Thesaurus Property)
    C1516147 (UMLS 2011AA Property)
    C48151 (NCI Thesaurus Property-2)
    C0079411 (UMLS 2011AA Property-2)
    PatientRandomizationDate
    Item
    Randomization Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25196 (NCI Thesaurus Property)
    C0034656 (UMLS 2011AA Property)
    Item Group
    Module 1
    PersonSpecimenMalignantNeoplasmResearchConsentInd-2
    Item
    Have you obtained the patient's consent for her tissue to be kept for use in research to learn about, prevent, treat, or cure cancer?
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C9305 (NCI Thesaurus Property-2)
    C0006826 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-3)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    BloodSpecimenMalignantNeoplasmRelatedResearchConsentIndicator
    Item
    Have you obtained the patient's consent for her blood to be kept for use in research to learn about, prevent, treat, or cure cancer?
    boolean
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25648 (NCI Thesaurus Property-2)
    C0439849 (UMLS 2011AA Property)
    C9305 (NCI Thesaurus Property-3)
    C0006826 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3
    Item
    Have you obtained the patient's consent for her tissue to be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)?
    boolean
    C12801 (NCI Thesaurus ObjectClass)
    C0040300 (UMLS 2011AA ObjectClass)
    C12434 (NCI Thesaurus ObjectClass-2)
    C0229664 (UMLS 2011AA ObjectClass-2)
    C19157 (NCI Thesaurus ObjectClass-3)
    C0370003 (UMLS 2011AA ObjectClass-3)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C15319 (NCI Thesaurus Property-2)
    C2991 (NCI Thesaurus Property-3)
    C0012634 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    BloodSpecimenOtherDiseasesandDisordersResearchConsentInd-3
    Item
    Have you obtained the patient's consent for her blood to be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)?
    boolean
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C15319 (NCI Thesaurus Property-2)
    C2991 (NCI Thesaurus Property-3)
    C0012634 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    Permission to contact Patient
    Item
    Have you obtained the patient's consent to allow someone from this institution to contact her in the future to take part in more research?
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C1522577 (UMLS CUI-1)
    C67527 (NCI Thesaurus Property)
    C0521104 (UMLS CUI-2)
    C25460 (NCI Thesaurus Property-2)
    C16452 (NCI Thesaurus Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    PatientBreastReconstructionConsentInd-2
    Item
    Patient has consented to participate in the cosmesis study
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    C15354 (NCI Thesaurus Property-2)
    C0085076 (UMLS 2011AA Property-2)
    Item
    If no, provide reason
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C49161 (NCI Thesaurus Property)
    C1705116 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property-2)
    C15354 (NCI Thesaurus Property-3)
    C0085076 (UMLS 2011AA Property-3)
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    If no, provide reason
    CL Item
    Patient Refused Due To Illness (Patient refused due to illness)
    CL Item
    Patient Refused For Other Reason (Patient refused for other reason)
    CL Item
    Not Approved By Institutional Irb (Not approved by institutional IRB)
    CL Item
    Tool Not Available In Patient's Language (Tool not available in patient's language)
    CL Item
    Other, Specify (Other, specify)
    PatientBreastReconstructionRefuseConsentOtherSpecify
    Item
    Patient refused for other reason: specify
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C49161 (NCI Thesaurus Property)
    C1705116 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property-2)
    C15354 (NCI Thesaurus Property-3)
    C0085076 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus ValueDomain-2)
    C0205394 (UMLS 2011AA ValueDomain-2)
    PatientBreastReconstructionRefuseConsentSpecify
    Item
    Other, specify
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C49161 (NCI Thesaurus Property)
    C1705116 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property-2)
    C15354 (NCI Thesaurus Property-3)
    C0085076 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    Age
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25320 (NCI Thesaurus Property)
    C1507394 (UMLS 2011AA Property)
    C25646 (NCI Thesaurus Property-2)
    C1514821 (UMLS 2011AA Property-2)
    C25509 (NCI Thesaurus Property-3)
    C1279901 (UMLS 2011AA Property-3)
    C29848 (NCI Thesaurus ValueDomain)
    C0439234 (UMLS 2011AA ValueDomain)
    C25463 (NCI Thesaurus ValueDomain-2)
    C0750480 (UMLS 2011AA ValueDomain-2)
    CL.12
    Code List
    Age
    CL Item
    < 50 (< 50)
    CL Item
    >= 50 (>= 50)
    PatientChemotherapyIntentReceiveInd-2
    Item
    Intention to receive chemotherapy
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15632 (NCI Thesaurus ObjectClass-2)
    C0392920 (UMLS 2011AA ObjectClass-2)
    C25639 (NCI Thesaurus Property)
    C1514756 (UMLS 2011AA Property)
    C25725 (NCI Thesaurus Property-2)
    C1283828 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item
    ER Status
    text
    C3262 (NCI Thesaurus ValueDomain)
    C0027651 (UMLS 2011AA ValueDomain)
    C17069 (NCI Thesaurus ObjectClass)
    C0034804 (UMLS 2011AA ObjectClass)
    C25688 (NCI Thesaurus ValueDomain-2)
    C0449438 (UMLS 2011AA ValueDomain-2)
    C25554 (NCI Thesaurus Property)
    C0441889 (UMLS 2011AA Property)
    CL.14
    Code List
    ER Status
    CL Item
    Positive (Positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Negative (Negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    Item
    Histologic Grade
    text
    C15206 (NCI Thesaurus ObjectClass)
    C0008972 (UMLS 2011AA ObjectClass)
    C4872 (NCI Thesaurus Property)
    C0678222 (UMLS 2011AA Property)
    C18000 (NCI Thesaurus Property-2)
    C0919553 (UMLS 2011AA Property-2)
    C25689 (NCI Thesaurus Property-3)
    C1514983 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.15
    Code List
    Histologic Grade
    CL Item
    Grade 1 And 2 (G1-2)
    CL Item
    Grade 3 (G3)
    Item Group
    Patient
    Item
    Radiation Therapy Technique
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16847 (NCI Thesaurus Property)
    C0449851 (UMLS 2011AA Property)
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    CL.16
    Code List
    Radiation Therapy Technique
    CL Item
    3-dimensional Conformal Radiation Therapy (3D-CRT)
    C16035 (NCI Thesaurus)
    C0600521 (UMLS 2011AA)
    CL Item
    Imrt (intensity Modulated Rt) (IMRT)
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