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)
PatientSignedDischargeMedicalRecordDate
Item
HIPAA Authorization Date (MM DD YYYY)
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)
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)
Item
ECOG Performance Status
text
C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)
Code List
ECOG Performance Status
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
Patient Height
Item
Height (cm)
float
C25209 (NCI Thesaurus ValueDomain)
C0489786 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)
Patient Weight
Item
Weight (kg)
float
C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
MedicalDictionaryforRegulatoryActivitiesTerminologyIdentifierCode
Item
Disease code (pancreas)
float
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
C43820 (NCI Thesaurus ValueDomain-2)
C1140263 (UMLS 2011AA ValueDomain-2)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible (for CALGB 61103)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
Item
ECOG Performance Status
text
C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)
Code List
ECOG Performance Status
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
Item
Prior Cancer Therapies (If patient received prior cancer therapy: Mark an X for each therapy received. For chemotherapies, specify number of regimens received. The number of regimens refers to the number of treatment courses, not the number of cycles received for a course of treatment. For example, a patient who received 3 cycles while on Treatment A and 6 cycles while on Treatment B has received 2 treatment regimens - Treatment A and Treatment B.)
text
C25284 (NCI Thesaurus ValueDomain)
C1514463 (UMLS CUI-1)
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25365 (NCI Thesaurus Property)
Code List
Prior Cancer Therapies (If patient received prior cancer therapy: Mark an X for each therapy received. For chemotherapies, specify number of regimens received. The number of regimens refers to the number of treatment courses, not the number of cycles received for a course of treatment. For example, a patient who received 3 cycles while on Treatment A and 6 cycles while on Treatment B has received 2 treatment regimens - Treatment A and Treatment B.)
CL Item
No Previous Exposure To Drug (nos) (No prior therapy)
CL Item
Agents Administered To Control The Replication And/or Spread Of Viruses (Anti-retroviral therapy)
CL Item
Treatment With An Agent That Prevents Or Impairs The Translation Of The Genetic Message For Production Of A Specific Protein (Antisense)
CL Item
High Dose Chemotherapy Combined With Transplantation Of Bone Marrow Cells (Bone marrow transplant)
CL Item
Systemic Chemotherapy With A Regimen Containing Multiple Agents (Chemotherapy multiple agents systemic)
CL Item
Prior Therapy With Agents That Are Not Known To Cause Damage To Cycling Cells (Chemotherapy non-cytotoxic)
CL Item
Non-systemic Chemotherapy Treatment Or Chemotherapy Not Described By Chemotherapy Single Agent Systemic Or Multi-agent Systemic (Chemotherapy (NOS))
CL Item
Systemic Chemotherapy With A Single Agent Regimen (Chemotherapy single agent systemic)
CL Item
Treatment Of Human Disease By Gene Transfer (Gene transfer)
CL Item
Image Directed Local Therapy (Image Directed Local Therapy)
CL Item
Cancer Therapy Which Incorporates Hormonal Manipulation (Hormonal therapy)
CL Item
Drug And/or Immunotherapy (Drug and/or Immunotherapy)
CL Item
Anticancer Treatment With A Live, Replication-competent Virus (Oncolytic virotherapy)
CL Item
Targeted Ionizing Radiation Therapy Utilizing Radioactive Implants Or Seeds (Radiation therapy)
CL Item
Surgical Procedure, Or Operation, With Therapeutic Intent (Surgery)
CL Item
Therapy Nos (Therapy (NOS))
CL Item
Substance Or Group Of Substances Administered To Induce The Immune System To Recognize And Destroy Tumors Or Microorganisms (Vaccine)
CL Item
Hematopoietic Stem Cell Transplantation (Hematopoietic Stem Cell Transplantation)
PriorMultipleAgentChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy multiple agents systemic)
float
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C17648 (NCI Thesaurus ObjectClass-3)
C0439064 (UMLS 2011AA ObjectClass-3)
C1708 (NCI Thesaurus ObjectClass-4)
C0450442 (UMLS 2011AA ObjectClass-4)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
PriorNon-cytotoxicAgentChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy non-cytotoxic)
float
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C83487 (NCI Thesaurus ObjectClass-3)
C2827065 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
PriorChemotherapyRegimenNumber
Item
Number of regimens (Chemotherapy - NOS)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
SingleAgentSystemicChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy single agent systemic)
float
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C15756 (NCI Thesaurus ObjectClass)
C0854619 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
PatientAncillaryStudyOneEligibilityDeterminationInd-3
Item
I choose to take part in the Patient-Reported Outcomes Study and agree to complete the questionnaire once per month (consent question #1 - must be Yes for participation in 71102)
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C66832 (NCI Thesaurus Property)
C0205447 (UMLS 2011AA Property)
C25171 (NCI Thesaurus Property-2)
C0013893 (UMLS 2011AA Property-2)
C16041 (NCI Thesaurus Property-3)
C1515980 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible (for CALGB 61103)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
PersonSpecimenMalignantNeoplasmResearchConsentInd-2
Item
My coded samples and related coded information may be used to learn about, prevent, find or treat my type of cancer. This may also include research on inherited traits (genes passed on in families) (consent question #2 - must be Yes for participation in 151109 and 61103)
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)
SpecimenResearchConsentSharedInd-3
Item
My coded samples and related coded information may be kept for use in future research to learn about, prevent, find or treat any type of cancer. This may also include research on inherited traits (genes passed on in families) (consent question #3)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property-2)
C1511481 (UMLS 2011AA Property)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible (for CALGB 61103)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2
Item
My coded samples and related coded information may be kept for use in future research to learn about, prevent, find or treat other health problems (for example: diabetes, Alzheimer's disease, or heart disease). This may also include research on inherited traits (genes passed on in families) (consent question #4)
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 my hospital or CALGB may contact me in the future to ask me to take part in more research (consent question #5)
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)
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible (for CALGB 61103)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)