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9030

Beschreibung

E3A06 Registration Worksheet (Step 1) Lenalidomide or Observation in Treating Patients With Asymptomatic High-Risk Smoldering Multiple Myeloma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8A5CBD48-79FD-0A96-E040-BB89AD43430D

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8A5CBD48-79FD-0A96-E040-BB89AD43430D

Stichworte

  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    Multiple Myeloma and Plasma Cell Neoplasm NCT01169337 Eligibility - E3A06 Registration Worksheet (Step 1) - 3116584v1.0

    No Instruction available.

    1. StudyEvent: E3A06 Registration Worksheet (Step 1)
      1. No Instruction available.
    Eligibility
    Beschreibung

    Eligibility

    Has the eligibility checklist been completed
    Beschreibung

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Datentyp

    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?
    Beschreibung

    Eligibility for trial

    Datentyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1302261
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25171
    Has written informed consent been obtained
    Beschreibung

    Consent signed

    Datentyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0742766
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25678
    NCI Thesaurus Property-2
    C25460
    Date Informed Consent Signed
    Beschreibung

    InformedConsentFormSignedDate

    Datentyp

    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
    Has HIPAA authorization been obtained
    Beschreibung

    HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C62504
    UMLS 2011AA ObjectClass
    C0600593
    NCI Thesaurus Property
    C41192
    UMLS 2011AA Property
    C1524004
    HIPAA Authorization Date
    Beschreibung

    PatientSignedDischargeMedicalRecordDate

    Datentyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25679
    NCI Metathesaurus Property
    C0012621
    NCI Thesaurus Property-2
    C45258
    UMLS 2011AA Property
    C0025102
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    Beschreibung

    PersonAncillaryStudyRegistrationText

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C16041
    UMLS 2011AA Property-2
    C1515980
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    Beschreibung

    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

    Datentyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C15207
    NCI Thesaurus Property-3
    C25294
    UMLS 2011AA Property-2
    C0022885
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    I agree to provide additional blood for research.
    Beschreibung

    PersonBloodTissueDonorConsentIndicator

    Datentyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25168
    UMLS 2011AA Property
    C0040288
    NCI Thesaurus Property-2
    C12434
    UMLS 2011AA Property-2
    C0229664
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Beschreibung

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Datentyp

    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
    My specimens may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
    Beschreibung

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Datentyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C12801
    UMLS 2011AA Property
    C0040300
    NCI Thesaurus Property-2
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Someone from this institution may contact me in the future to ask me to take part in more research.
    Beschreibung

    PatientAdditionalResearchConsentInd-2

    Datentyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25406
    UMLS 2011AA Property
    C1524062
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698

    Ähnliche Modelle

    No Instruction available.

    1. StudyEvent: E3A06 Registration Worksheet (Step 1)
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Eligibility
    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)
    Consent signed
    Item
    Has written informed consent been obtained
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C0742766 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25678 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    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)
    Item
    Has HIPAA authorization been obtained
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C62504 (NCI Thesaurus ObjectClass)
    C0600593 (UMLS 2011AA ObjectClass)
    C41192 (NCI Thesaurus Property)
    C1524004 (UMLS 2011AA Property)
    Code List
    Has HIPAA authorization been obtained
    CL Item
    No: C49487 (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes: C49488 (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Exempt - Non-usa Participant (Exempt - non-USA participant)
    PatientSignedDischargeMedicalRecordDate
    Item
    HIPAA Authorization Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C0012621 (NCI Metathesaurus Property)
    C45258 (NCI Thesaurus Property-2)
    C0025102 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    PersonAncillaryStudyRegistrationText
    Item
    If the patient has been registered to E3A05, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    C16041 (NCI Thesaurus Property-2)
    C1515980 (UMLS 2011AA Property-2)
    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2
    Item
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C15207 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus Property-3)
    C0022885 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PersonBloodTissueDonorConsentIndicator
    Item
    I agree to provide additional blood for research.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25168 (NCI Thesaurus Property)
    C0040288 (UMLS 2011AA Property)
    C12434 (NCI Thesaurus Property-2)
    C0229664 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    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)
    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2
    Item
    My specimens may be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, or heart disease)
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C12801 (NCI Thesaurus Property)
    C0040300 (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)
    PatientAdditionalResearchConsentInd-2
    Item
    Someone from this institution may contact me in the future to ask me to take part in more research.
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C25406 (NCI Thesaurus Property-2)
    C1524062 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)

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