PatientFirstInitialsName
Item
First initial
text
PatientLastInitialsName
Item
Last initial
text
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)
SpecimenSubmissionContactPersonIdentifierName
Item
Name of the contact person responsible for sample submission
text
SpecimenSubmissionContactPersonTelephoneNumber
Item
Phone number of the contact person responsible for sample submission
text
SpecimenSubmissionContactPersonFaxNumber
Item
Fax number of the contact person responsible for sample submission
text
SpecimenSubmissionContactPersonE-mailAddressText
Item
E-mail address of the contact person responsible for sample submission
text
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)
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)
PersonBloodTissueDonorConsentIndicator
Item
I agree to donate 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 research about other health problems (for example: causes of diabetes, Alzheimer's disease, and 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)
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)
Item
Race (check all that apply)
text
Code List
Race (check all that apply)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
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)
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)
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)
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)
CL Item
Not Provided Or Available (Not Reported)
CL Item
Could Not Be Determined Or Unsure (Unknown)
PatientBirthDate
Item
Birthdate (mm/yy)
date
AddressPostalCodeIdentifier
Item
ZIP Code
text
Item
Patient Ethnicity
text
Code List
Patient Ethnicity
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)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
CL Item
Not Provided Or Available (Not reported)
CL Item
Could Not Be Determined Or Unsure (Unknown)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
PatientSSNNumber
Item
Patient Social Security Number
text
Item
Method of payment (check one)
text
Code List
Method of payment (check one)
CL Item
Private Insurance (Private Insurance)
CL Item
Medicare (Medicare)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Medicaid (Medicaid)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Military Or Veterans Sponsored Nos (Military or Veterans Sponsored, Not Otherwise Specified (NOS))
CL Item
Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
CL Item
Veterans Sponsored (Veterans Sponsored)
CL Item
Self Pay (no Insurance) (Self Pay (No Insurance))
CL Item
No Means Of Payment (no Insurance) (No means of payment (no insurance))
CL Item
Unknown (Unknown)
AttendingPhysicianIdentifierIndividualsName
Item
Attending Physician
text
InstitutionContactPersonName
Item
Institution contact
text
ProtocolRegistrarName
Item
Registrar
text
Item
Country of Residence (if not USA)
text
Code List
Country of Residence (if not USA)
CL Item
Ascension Island (AC)
CL Item
United Arab Emirates (AE)
CL Item
Antigua And Barbuda (AG)
CL Item
Netherland Antilles (AN)
CL Item
American Samoa (AS)
CL Item
Bosnia-herzegovina (BA)
CL Item
Burkina Faso (BF)
CL Item
Brunei Darussalam (BN)
CL Item
Bouvet Island (BV)
CL Item
Rep. Dem. Congo (CD)
CL Item
Central African Rep. (CF)
CL Item
Cook Islands (CK)
CL Item
Christmas Island (CX)
CL Item
Czech Republic (CZ)
CL Item
Dominican Republic (DO)
CL Item
Western Sahara (EH)
CL Item
Falkland Isl. (FK)
CL Item
Faroe Islands (FO)
CL Item
France (european Ter.) (FX)
CL Item
Great Britain (GB)
CL Item
Guiana (fr.) (GF)
CL Item
Guadeloupe (fr.) (GP)
CL Item
Equatorial Guinea (GQ)
CL Item
South Georgia And South Sandwich Islands (GS)
CL Item
Guinea Bissau (GW)
CL Item
Heard & Mcdonald Isl. (HM)
CL Item
British Indian O. Ter. (IO)
CL Item
Kyrgyz Republic (KG)
CL Item
St. Kitts Nevis Anguilla (KN)
CL Item
Korea (north) (KP)
CL Item
Korea (south) (KR)
CL Item
Cayman Islands (KY)
CL Item
Liechtenstein (LI)
CL Item
Marshall Islands (MH)
CL Item
Northern Mariana Isl. (MP)
CL Item
Martinique (fr.) (MQ)
CL Item
New Caledonia (fr.) (NC)
CL Item
Norfolk Island (NF)
CL Item
Polynesia (fr.) (PF)
CL Item
Papua New Guinea (PG)
CL Item
St. Pierre & Miquelon (PM)
CL Item
Reunion (fr.) (RE)
CL Item
Russian Federation (RU)
CL Item
Saudi Arabia (SA)
CL Item
Solomon Islands (SB)
CL Item
Svalbard & Jan Mayen Isl. (SJ)
CL Item
Sierra Leone (SL)
CL Item
St. Tome And Principe (ST)
CL Item
Soviet Union (SU)
CL Item
Turks & Caicos Islands (TC)
CL Item
French Southern Terr. (TF)
CL Item
Turkmenistan (TM)
CL Item
Trinidad & Tobago (TT)
CL Item
United Kingdom (UK)
CL Item
Us Minor Outlying Isl. (UM)
CL Item
Vatican City State (VA)
CL Item
St. Vincent & Grenadines (VC)
CL Item
Virgin Islands (brit) (VG)
CL Item
Virgin Islands (us) (VI)
CL Item
Wallis & Futuna Islands (WF)
CL Item
Western Samoa (WS)
CL Item
South Africa (ZA)
CL Item
Dem. Rep. Of Congo (ZR)
ResearchCommentsText
Item
Comments
text