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9012

Description

Southwest Oncology Group S0833 Registration Worksheet Bortezomib, Thalidomide, Lenalidomide, Combination Chemotherapy, and Autologous Stem Cell Transplant in Treating Patients With Newly Diagnosed Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9BB380AB-89F9-FD3C-E040-BB89AD436314

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9BB380AB-89F9-FD3C-E040-BB89AD436314

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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    Multiple Myeloma and Plasma Cell Neoplasm NCT01055301 Registration - Southwest Oncology Group S0833 Registration Worksheet - 3189708v1.0

    Anglais

    INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.

    1 Formulaires  
    Header
    Description

    Header

    Activation Date (MM DD YYYY)
    Description

    ClinicalStudyProtocolAmendmentActivationDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS 2011AA ObjectClass
    C1507394 (Clinical trial protocol document)
    LOINC
    LP33258-2
    NCI Thesaurus Property
    C64382 (undefined)
    UMLS 2011AA Property
    C1879547 (Activation action)
    LOINC
    LA29299-7
    NCI Thesaurus Property-2
    C41200 (undefined)
    UMLS 2011AA Property-2
    C0680532 (Amendment)
    Last Amended Date (MM DD YYYY)
    Description

    DataAmendedLastDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    UMLS 2011AA ObjectClass
    C1511726 (Data)
    NCI Thesaurus Property
    C25416 (undefined)
    UMLS 2011AA Property
    C1691222 (Amended)
    NCI Thesaurus ValueDomain-2
    C25551 (undefined)
    UMLS 2011AA ValueDomain-2
    C1517741 (Last)
    LOINC
    LP200101-6
    Registration Step
    Description

    Registration Number

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C1514821 (Registration)
    NCI Thesaurus ObjectClass
    C25646 (undefined)
    UMLS CUI-2
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C16154 (undefined)
    NCI Thesaurus ValueDomain-2
    C16154 (undefined)
    Swog Patient Id
    Description

    Swog Patient Id

    SWOG Patient ID Status
    Description

    PatientSouthwestOncologyGroupIdentifierStatus

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property-2
    C25699 (undefined)
    UMLS 2011AA Property-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ValueDomain
    C25688 (undefined)
    UMLS 2011AA ValueDomain
    C0449438 (Status)
    SNOMED
    263490005
    LOINC
    LP73412-6
    SWOG Patient ID
    Description

    Trial subject ID SWOG

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C2348585 (Clinical Trial Subject Unique Identifier)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus Property-2
    C25699 (undefined)
    Demography
    Description

    Demography

    Patient First Name
    Description

    First Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1443235 (First Name)
    SNOMED
    408677003
    LOINC
    MTHU048693
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus Property-2
    C25509 (undefined)
    Patient Middle Name
    Description

    PatientMiddleName

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property-2
    C25569 (undefined)
    UMLS 2011AA Property-2
    C0444598 (Middle)
    SNOMED
    255562008
    LOINC
    LA26546-4
    Patient Last Name
    Description

    Last Name

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1301584 (Last Name)
    SNOMED
    397678008
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus Property-2
    C25551 (undefined)
    Unnamed2
    Description

    Unnamed2

    Registrar's SWOG Roster ID Number
    Description

    RegistrarSouthwestOncologyGroupIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus Property-2
    C25699 (undefined)
    UMLS 2011AA Property-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass
    C25357 (undefined)
    UMLS 2011AA ObjectClass
    C0557514 (Registrar)
    SNOMED
    224531000
    LOINC
    LA4379-9
    SWOG Investigator Number
    Description

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Type de données

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25699 (undefined)
    UMLS 2011AA ObjectClass
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass-2
    C17089 (undefined)
    UMLS 2011AA ObjectClass-2
    C0035173 (Research Personnel)
    SNOMED
    769038007
    LOINC
    LA23773-7
    SWOG Treating Institution Number
    Description

    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

    Type de données

    float

    Alias
    NCI Thesaurus ObjectClass
    C25699 (undefined)
    UMLS 2011AA ObjectClass
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus ObjectClass-2
    C25705 (undefined)
    UMLS 2011AA ObjectClass-2
    C1522326 (Treating)
    NCI Thesaurus ObjectClass-3
    C41206 (undefined)
    UMLS 2011AA ObjectClass-3
    C1272753 (Institution (social concept))
    SNOMED
    385437003
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    Unnamed5
    Description

    Unnamed5

    Date Informed Consent Signed (MM DD YYYY)
    Description

    InformedConsentFormSignedDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)
    NCI Thesaurus ObjectClass
    C16468 (undefined)
    UMLS 2011AA ObjectClass
    C0009797 (Consent Forms)
    NCI Thesaurus Property
    C25679 (undefined)
    Date HIPAA Authorization signed (Not required if Country of Residence is not USA MM DD YYYY)
    Description

    HIPAA Approval Date

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C0600593 (Health Insurance Portability and Accountability Act)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C2346844 (Approval Date)
    NCI Thesaurus Property
    C25425 (undefined)
    Projected Start Date of Treatment (MM DD YYYY)
    Description

    Treatment Begin Date

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus ObjectClass-2
    C25631 (undefined)
    NCI Thesaurus Property
    C25431 (undefined)
    UMLS CUI-1
    C3173309 (Date treatment or therapy started)
    LOINC
    LP262646-5
    NCI Thesaurus Property-2
    C25275 (undefined)
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ValueDomain-2
    C25431 (undefined)
    Unnamed4
    Description

    Unnamed4

    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Description

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    UMLS 2011AA ObjectClass
    C0027361 (Persons)
    SNOMED
    125676002
    NCI Thesaurus Property
    C15319 (undefined)
    NCI Thesaurus Property-2
    C9305 (undefined)
    UMLS 2011AA Property
    C0006826 (Malignant Neoplasms)
    SNOMED
    363346000
    LOINC
    LP100805-3
    NCI Thesaurus Property-3
    C19157 (undefined)
    UMLS 2011AA Property-2
    C0370003 (Specimen)
    SNOMED
    123038009
    LOINC
    LP7593-9
    NCI Thesaurus Property-4
    C25460 (undefined)
    UMLS 2011AA Property-3
    C1511481 (Consent)
    LOINC
    LP100037-3
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
    Description

    PatientOtherDiseaseorDisorderClinicalStudyConsentInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C17649 (undefined)
    UMLS 2011AA Property
    C0205394 (Other)
    SNOMED
    74964007
    LOINC
    LP21049-9
    NCI Thesaurus Property-2
    C2991 (undefined)
    UMLS 2011AA Property-2
    C0012634 (Disease)
    SNOMED
    64572001
    LOINC
    LP21006-9
    NCI Thesaurus Property-3
    C15206 (undefined)
    UMLS 2011AA Property-3
    C0008972 (Clinical Research)
    NCI Thesaurus Property-4
    C25460 (undefined)
    UMLS 2011AA Property-4
    C1511481 (Consent)
    LOINC
    LP100037-3
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    Someone may contact me in the future to ask me to allow other uses of my specimens.
    Description

    Permission to contact Patient

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-1
    C1522577 (follow-up)
    NCI Thesaurus Property
    C67527 (undefined)
    UMLS CUI-2
    C0521104 (permission)
    SNOMED
    75554001
    NCI Thesaurus Property-2
    C25460 (undefined)
    NCI Thesaurus Property-3
    C16452 (undefined)
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    I agree to allow my study doctor, or someone approved by my study doctor, to contact me regarding future research involving my participation in this study.
    Description

    SouthwestOncologyGroupPatientResearchConsentInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ObjectClass-2
    C25699 (undefined)
    UMLS 2011AA ObjectClass-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus Property
    C15319 (undefined)
    NCI Thesaurus Property-2
    C25460 (undefined)
    UMLS 2011AA Property
    C1511481 (Consent)
    LOINC
    LP100037-3
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    I agree to have my bone marrow submitted for this testing.
    Description

    PersonBoneMarrowSpecimenConsentInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    UMLS 2011AA ObjectClass
    C0027361 (Persons)
    SNOMED
    125676002
    NCI Thesaurus Property
    C12431 (undefined)
    UMLS 2011AA Property
    C0005953 (Bone Marrow)
    SNOMED
    279729006
    LOINC
    LP7410-6
    NCI Thesaurus Property-2
    C19157 (undefined)
    UMLS 2011AA Property-2
    C0370003 (Specimen)
    SNOMED
    123038009
    LOINC
    LP7593-9
    NCI Thesaurus Property-3
    C25460 (undefined)
    UMLS 2011AA Property-3
    C1511481 (Consent)
    LOINC
    LP100037-3
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    Unnamed 7
    Description

    Unnamed 7

    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
    Description

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ObjectClass-2
    C25699 (undefined)
    UMLS 2011AA ObjectClass-2
    C1519429 (SWOG)
    LOINC
    LA4458-1
    NCI Thesaurus Property
    C25646 (undefined)
    UMLS 2011AA Property
    C1514821 (Registration)
    NCI Thesaurus Property-2
    C25171 (undefined)
    UMLS 2011AA Property-2
    C0013893 (Eligibility Determination)
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    Retour au début de la page

    Similar models

    INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.

    1 Formulaires
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header
    ClinicalStudyProtocolAmendmentActivationDate
    Item
    Activation Date (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C64382 (NCI Thesaurus Property)
    C1879547 (UMLS 2011AA Property)
    C41200 (NCI Thesaurus Property-2)
    C0680532 (UMLS 2011AA Property-2)
    DataAmendedLastDate
    Item
    Last Amended Date (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus ValueDomain-2)
    C1517741 (UMLS 2011AA ValueDomain-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Item Group
    Swog Patient Id
    Item
    SWOG Patient ID Status
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property-2)
    C1519429 (UMLS 2011AA Property-2)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.1
    Code List
    SWOG Patient ID Status
    CL Item
    New Patient (New patient)
    CL Item
    Previous Patient (Previous patient)
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Item Group
    Demography
    First Name
    Item
    Patient First Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1443235 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    C25509 (NCI Thesaurus Property-2)
    PatientMiddleName
    Item
    Patient Middle Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25569 (NCI Thesaurus Property-2)
    C0444598 (UMLS 2011AA Property-2)
    Last Name
    Item
    Patient Last Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301584 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    Item Group
    Unnamed2
    RegistrarSouthwestOncologyGroupIdentifierNumber
    Item
    Registrar's SWOG Roster ID Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property-2)
    C1519429 (UMLS 2011AA Property-2)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS 2011AA ObjectClass)
    SouthwestOncologyGroupInvestigatorIdentifierNumber
    Item
    SWOG Investigator Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C17089 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber
    Item
    SWOG Treating Institution Number
    float
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    C41206 (NCI Thesaurus ObjectClass-3)
    C1272753 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    Item Group
    Unnamed5
    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)
    HIPAA Approval Date
    Item
    Date HIPAA Authorization signed (Not required if Country of Residence is not USA MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0600593 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2346844 (UMLS CUI-2)
    C25425 (NCI Thesaurus Property)
    Treatment Begin Date
    Item
    Projected Start Date of Treatment (MM DD YYYY)
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25631 (NCI Thesaurus ObjectClass-2)
    C25431 (NCI Thesaurus Property)
    C3173309 (UMLS CUI-1)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    PersonSpecimenMalignantNeoplasmResearchConsentInd-2
    Item
    My specimens may 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)
    PatientOtherDiseaseorDisorderClinicalStudyConsentInd-2
    Item
    My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C2991 (NCI Thesaurus Property-2)
    C0012634 (UMLS 2011AA Property-2)
    C15206 (NCI Thesaurus Property-3)
    C0008972 (UMLS 2011AA Property-3)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Permission to contact Patient
    Item
    Someone may contact me in the future to ask me to allow other uses of my specimens.
    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)
    SouthwestOncologyGroupPatientResearchConsentInd-2
    Item
    I agree to allow my study doctor, or someone approved by my study doctor, to contact me regarding future research involving my participation in this study.
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PersonBoneMarrowSpecimenConsentInd-2
    Item
    I agree to have my bone marrow submitted for this testing.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C12431 (NCI Thesaurus Property)
    C0005953 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-2)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item Group
    Unnamed 7
    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2
    Item
    Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus Property-2)
    C0013893 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
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