ID

8896

Description

RTOG 1010 Demographic Data Form (A5) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666BB88-BFD1-08B9-E040-BB89AD434AC6

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666BB88-BFD1-08B9-E040-BB89AD434AC6

Keywords

Versions (4)
  1. 8/26/12 8/26/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG 1010 Demographic Data Form (A5) - 3085100v1.0

English

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

1 forms  
Header
Description

Header

RTOG Study No.
Description

Protocol ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
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
Institution No.
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
Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Description

Trial subject ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Unnamed2
Description

Unnamed2

Date Completed (mm-dd-yyyy)
Description

FormCompletionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Amended Data
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Who completed this form (Check one box)
Description

ResponsiblePersonDescriptionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C25657
UMLS 2011AA ObjectClass-2
C1273518
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Patient Race Category (Check all that apply)
Description

Racial Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS CUI-1
C0034510
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17049
Patient Ethnic Group Cateogy (Check one box)
Description

Ethnic Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS CUI-1
C0015031
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C16564
Highest school grade completed (Check one box)
Description

PersonHighestEducationType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property-2
C25525
UMLS 2011AA Property-2
C1522410
Other, specify
Description

PersonHighestEducationSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property-2
C25525
UMLS 2011AA Property-2
C1522410
Religion during childhood (Check one box)
Description

PersonPediatricReligionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property-2
C17085
UMLS 2011AA Property-2
C0035039
Other, specify
Description

PersonPediatricReligionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus Property-2
C17085
UMLS 2011AA Property-2
C0035039
Marital status (Check one box)
Description

MaritalStatusDescriptionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25188
UMLS 2011AA ObjectClass
C0024819
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Where were you born (Check one box Check the box of the country where you were born)
Description

PersonBirthCountryType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25464
UMLS 2011AA Property
C0454664
NCI Thesaurus Property-2
C25155
UMLS 2011AA Property-2
C0005615
USA, specify the 2 letter State code (eg NY)
Description

PatientBirthStateSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C30010
UMLS 2011AA Property
C1301808
NCI Thesaurus Property-2
C25155
UMLS 2011AA Property-2
C0005615
Other country, specify
Description

PersonBirthCountryIndividualSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25464
UMLS 2011AA Property
C0454664
NCI Thesaurus Property-2
C25155
UMLS 2011AA Property-2
C0005615
Where did you live the longest (Check one box)
Description

PatientLongestDurationResidenceType

Data type

text

Alias
NCI Metathesaurus ObjectClass
C0030705
NCI Thesaurus Property
C25558
UMLS 2011AA Property
C1522425
NCI Thesaurus Property-2
C25330
UMLS 2011AA Property-2
C0449238
NCI Thesaurus Property-3
C25273
UMLS 2011AA Property-3
C0237096
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
USA, specify the 2 letter State code (eg NY)
Description

PatientStateLongestDurationResidenceCode

Data type

text

Alias
NCI Metathesaurus ObjectClass
C0030705
NCI Thesaurus Property
C25558
UMLS 2011AA Property
C1522425
NCI Thesaurus Property-2
C30010
UMLS 2011AA Property-2
C1301808
NCI Thesaurus Property-3
C25330
UMLS 2011AA Property-3
C0449238
NCI Thesaurus Property-4
C25273
UMLS 2011AA Property-4
C0237096
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ValueDomain-2
C30010
UMLS 2011AA ValueDomain-2
C1301808
Other country, specify
Description

PatientCountryLongestDurationResidenceName

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25558
UMLS 2011AA Property
C1522425
NCI Thesaurus Property-2
C25464
UMLS 2011AA Property-2
C0454664
NCI Thesaurus Property-3
C25330
UMLS 2011AA Property-3
C0449238
NCI Thesaurus Property-4
C25273
UMLS 2011AA Property-4
C0237096
NCI Thesaurus ValueDomain
C25464
UMLS 2011AA ValueDomain
C0454664
NCI Thesaurus ValueDomain-2
C42614
UMLS 2011AA ValueDomain-2
C0027365
Cigarette History
Description

Cigarette History

Smoked at least 100 cigarette during lifetime (5 packs)
Description

Smoked at least 100 cigarettes during lifetime (5 packs)

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C29719
UMLS CUI-1
C1519384
Age began smoking cigarettes
Description

Patient Initial Cigarette Smoking Age Year Count

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NCI Thesaurus Property-2
C18270
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
UMLS CUI-1
C1519384
Number of years smoked cigarettes
Description

Cigarettes Smoking Year Number

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C1802
NCI Thesaurus ValueDomain-2
C29848
NCI Thesaurus Property
C17934
UMLS CUI-1
C1519384
Average number of cigarettes smoked per day
Description

Smoking Use Average Number

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C17934
NCI Thesaurus Property
C25340
UMLS CUI-1
C1519384
If quit, age stopped smoking completely
Description

Patient Smoking Cessation Age Year

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
NCI Metathesaurus Property
C0085134
UMLS CUI-1
C1519384
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
Description

Other Disease Diagnosis Type

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C17649
NCI Thesaurus ObjectClass-2
C2991
NCI Thesaurus Property
C15220
UMLS CUI-1
C2359476
Specify other
Description

Other Disease Diagnosis Specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C17649
NCI Thesaurus ObjectClass-2
C2991
NCI Thesaurus Property
C15220
UMLS CUI-1
C2359476
Family History
Description

Family History

How many brothers do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
Description

BrotherPatientFamilyMembersAssessmentNumber

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25289
UMLS 2011AA ObjectClass-2
C0337527
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0086282
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
How many sisters do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
Description

SisterPatientFamilyMembersAssessmentNumber

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25680
UMLS 2011AA ObjectClass-2
C0337514
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0086282
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
How many sons do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
Description

SonPatientFamilyMembersAssessmentNumber

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25205
UMLS 2011AA ObjectClass-2
C0037683
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0086282
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
How many daughters do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
Description

DaughterPatientFamilyMembersAssessmentNumber

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25165
UMLS 2011AA ObjectClass-2
C0011011
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0086282
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Are you adopted (Check one In 10C; complete the question only for your children; omit mother, father, sisters, brothers)
Description

PatientAdoptedInd-3

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25290
UMLS 2011AA Property
C0425382
Blood relative with cancer (check = yes)
Description

RelativeFamilyCancerHistoryType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25173
UMLS 2011AA ObjectClass
C0015576
NCI Thesaurus ObjectClass-2
C21480
UMLS 2011AA ObjectClass-2
C0080103
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Age when first cancer diagnosed
Description

PersonFirstCancerDiagnosisAgeYearCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-2
C25509
UMLS 2011AA Property-2
C1279901
NCI Thesaurus Property-3
C15220
UMLS 2011AA Property-3
C0011900
NCI Thesaurus Property-4
C25150
UMLS 2011AA Property-4
C0001779
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Type of Cancer (check = yes)
Description

CancerSiteType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
Specify
Description

CancerSiteSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
Have you ever heard of Cancer Prevention Trials (Check one box By Cancer Prevention Trials we mean studies in which healthy people, including cured cancer patients, volunteer to take part in experimental cancer prevention, such as the use of special diets and new drugs. People volunteer in order to obtain the newest prevention for themselves and to help scientists learn how well the new prevention methods work)
Description

CancerPreventionTrialKnowledgeDocumentedInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Metathesaurus Property
C0376554
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
Description

CancerPreventionTrialParticipationScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
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Similar models

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Unnamed2
FormCompletionDate
Item
Date Completed (mm-dd-yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Data amended
Item
Amended Data
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item
Who completed this form (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C1273518 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.2
Code List
Who completed this form (Check one box)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Staff (Staff)
CL Item
Other Person (Other person)
CL Item
Not Applicable, No Items Completed (Not applicable, no items completed)
Item
Patient Race Category (Check all that apply)
text
C25372 (NCI Thesaurus ValueDomain)
C0034510 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
CL.3
Code List
Patient Race Category (Check all that apply)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
Item
Patient Ethnic Group Cateogy (Check one box)
text
C25372 (NCI Thesaurus ValueDomain)
C0015031 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C16564 (NCI Thesaurus Property)
CL.4
Code List
Patient Ethnic Group Cateogy (Check one box)
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (HISPANIC OR LATINO)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (NOT HISPANIC OR LATINO)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Highest school grade completed (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
CL.5
Code List
Highest school grade completed (Check one box)
CL Item
8th Or Less (8th or less)
CL Item
9 - 11th Grade (9 - 11th Grade)
CL Item
High School Graduate / Ged (High school graduate/GED)
CL Item
Vocational / Technical School (Vocational/technical school)
CL Item
Associate Degree / Some College (Associate degree/some college)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
PersonHighestEducationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
Item
Religion during childhood (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
CL.6
Code List
Religion during childhood (Check one box)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Morman/Latter Day Saints)
CL Item
Muslim / Islam (Muslim/Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
PersonPediatricReligionSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
Item
Marital status (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25188 (NCI Thesaurus ObjectClass)
C0024819 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.7
Code List
Marital status (Check one box)
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
CL Item
Domestic Partnership (Domestic Partnership)
C53262 (NCI Thesaurus)
C1549111 (UMLS 2011AA)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Never Married (Never married)
C51774 (NCI Thesaurus)
C0027952 (UMLS 2011AA)
CL Item
Separated (Separated)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Item
Where were you born (Check one box Check the box of the country where you were born)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
CL.8
Code List
Where were you born (Check one box Check the box of the country where you were born)
CL Item
Usa (USA)
CL Item
Other Country (Other country)
PatientBirthStateSpecify
Item
USA, specify the 2 letter State code (eg NY)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C30010 (NCI Thesaurus Property)
C1301808 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
PersonBirthCountryIndividualSpecify
Item
Other country, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25464 (NCI Thesaurus Property)
C0454664 (UMLS 2011AA Property)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
Item
Where did you live the longest (Check one box)
text
C0030705 (NCI Metathesaurus ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25330 (NCI Thesaurus Property-2)
C0449238 (UMLS 2011AA Property-2)
C25273 (NCI Thesaurus Property-3)
C0237096 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.9
Code List
Where did you live the longest (Check one box)
CL Item
Usa (USA)
CL Item
Other Country (Other country)
PatientStateLongestDurationResidenceCode
Item
USA, specify the 2 letter State code (eg NY)
text
C0030705 (NCI Metathesaurus ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C30010 (NCI Thesaurus Property-2)
C1301808 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C30010 (NCI Thesaurus ValueDomain-2)
C1301808 (UMLS 2011AA ValueDomain-2)
PatientCountryLongestDurationResidenceName
Item
Other country, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25464 (NCI Thesaurus Property-2)
C0454664 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus Property-3)
C0449238 (UMLS 2011AA Property-3)
C25273 (NCI Thesaurus Property-4)
C0237096 (UMLS 2011AA Property-4)
C25464 (NCI Thesaurus ValueDomain)
C0454664 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0027365 (UMLS 2011AA ValueDomain-2)
Item Group
Cigarette History
Item
Smoked at least 100 cigarette during lifetime (5 packs)
integer
C25180 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
C1519384 (UMLS CUI-1)
CL.10
Code List
Smoked at least 100 cigarette during lifetime (5 packs)
CL Item
No (0)
CL Item
Yes, But Quit (1)
CL Item
Yes, Currently Smoke (2)
Age began smoking cigarettes
Item
Age began smoking cigarettes
integer
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C18270 (NCI Thesaurus Property-2)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C1519384 (UMLS CUI-1)
Number of years smoked cigarettes
Item
Number of years smoked cigarettes
integer
C25337 (NCI Thesaurus ValueDomain)
C1802 (NCI Thesaurus ObjectClass)
C29848 (NCI Thesaurus ValueDomain-2)
C17934 (NCI Thesaurus Property)
C1519384 (UMLS CUI-1)
Cigarettes smoked per day
Item
Average number of cigarettes smoked per day
integer
C25337 (NCI Thesaurus ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C25340 (NCI Thesaurus Property)
C1519384 (UMLS CUI-1)
Smoking Cessation Age
Item
If quit, age stopped smoking completely
integer
C16960 (NCI Thesaurus ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0085134 (NCI Metathesaurus Property)
C1519384 (UMLS CUI-1)
Item
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
integer
C25284 (NCI Thesaurus ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C15220 (NCI Thesaurus Property)
C2359476 (UMLS CUI-1)
CL.11
Code List
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
CL Item
Heart Problems (1)
CL Item
Lung Problems (2)
CL Item
High Blood Pressure (3)
CL Item
Bleeding Problems (4)
CL Item
Circulation Problems (5)
CL Item
Liver Problems (6)
CL Item
Diabetes Or Sugar In Urine (7)
CL Item
Kidney/urine Problems (8)
CL Item
Stroke (9)
CL Item
Thyroid Problems (10)
CL Item
Seizure (11)
CL Item
Hiv/aids (12)
CL Item
Frequent Infections (13)
CL Item
Psychological Problems (14)
CL Item
Other (15)
Other diseases text
Item
Specify other
text
C25685 (NCI Thesaurus ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C15220 (NCI Thesaurus Property)
C2359476 (UMLS CUI-1)
Item Group
Family History
BrotherPatientFamilyMembersAssessmentNumber
Item
How many brothers do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25289 (NCI Thesaurus ObjectClass-2)
C0337527 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0086282 (NCI Metathesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
SisterPatientFamilyMembersAssessmentNumber
Item
How many sisters do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25680 (NCI Thesaurus ObjectClass-2)
C0337514 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0086282 (NCI Metathesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
SonPatientFamilyMembersAssessmentNumber
Item
How many sons do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25205 (NCI Thesaurus ObjectClass-2)
C0037683 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0086282 (NCI Metathesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
DaughterPatientFamilyMembersAssessmentNumber
Item
How many daughters do you have (How many of the following family members living and dead do you have? Include only those who are blood-related)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25165 (NCI Thesaurus ObjectClass-2)
C0011011 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0086282 (NCI Metathesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientAdoptedInd-3
Item
Are you adopted (Check one In 10C; complete the question only for your children; omit mother, father, sisters, brothers)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
Item
Blood relative with cancer (check = yes)
text
C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus ObjectClass-2)
C0080103 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
Blood relative with cancer (check = yes)
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)
CL Item
Brother #1 (Brother #1)
CL Item
Brother #2 (Brother #2)
CL Item
Brother #3 (Brother #3)
CL Item
Brother #4 (Brother #4)
CL Item
Sister #1 (Sister #1)
CL Item
Sister #2 (Sister #2)
CL Item
Sister #3 (Sister #3)
CL Item
Sister #4 (Sister #4)
CL Item
Child #1 (Child #1)
CL Item
Child #2 (Child #2)
CL Item
Child #3 (Child #3)
CL Item
Child #4 (Child #4)
PersonFirstCancerDiagnosisAgeYearCount
Item
Age when first cancer diagnosed
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25150 (NCI Thesaurus Property-4)
C0001779 (UMLS 2011AA Property-4)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Type of Cancer (check = yes)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
CL.14
Code List
Type of Cancer (check = yes)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Head & Neck (Head & Neck)
CL Item
Non Melanoma Skin (Non Melanoma Skin)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CancerSiteSpecify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
CancerPreventionTrialKnowledgeDocumentedInd-2
Item
Have you ever heard of Cancer Prevention Trials (Check one box By Cancer Prevention Trials we mean studies in which healthy people, including cured cancer patients, volunteer to take part in experimental cancer prevention, such as the use of special diets and new drugs. People volunteer in order to obtain the newest prevention for themselves and to help scientists learn how well the new prevention methods work)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
Item
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
CL.16
Code List
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
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