ID

9105

Beskrivning

Southwest Oncology Group S0812 Registration Worksheet Form (Step 1) High Dose Cholecalciferol in Premenopausal Women at High-Risk for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AE8F0868-7F44-FEC9-E040-BB89AD4357E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AE8F0868-7F44-FEC9-E040-BB89AD4357E7

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    brca1 Mutation Carrier NCT01097278 Registration - Southwest Oncology Group S0812 Registration Worksheet Form (Step 1) - 3289182v1.0

    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.

    Header
    Beskrivning

    Header

    Activation Date (MM DD YYYY)
    Beskrivning

    ClinicalStudyProtocolAmendmentActivationDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C64382
    UMLS 2011AA Property
    C1879547
    NCI Thesaurus Property-2
    C41200
    UMLS 2011AA Property-2
    C0680532
    Last Amended Date (MM DD YYYY)
    Beskrivning

    DataAmendedLastDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain-2
    C25551
    UMLS 2011AA ValueDomain-2
    C1517741
    Registration Step
    Beskrivning

    Registration Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Swog Patient Id
    Beskrivning

    Swog Patient Id

    SWOG Patient ID Status
    Beskrivning

    PatientSouthwestOncologyGroupIdentifierStatus

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25699
    UMLS 2011AA Property-2
    C1519429
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    SWOG Patient ID
    Beskrivning

    Trial subject ID SWOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Demography
    Beskrivning

    Demography

    Patient First Name
    Beskrivning

    First Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1443235
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25509
    Patient Middle Name
    Beskrivning

    PatientMiddleName

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25569
    UMLS 2011AA Property-2
    C0444598
    Patient Last Name
    Beskrivning

    Last Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301584
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25551
    Unnamed2
    Beskrivning

    Unnamed2

    Registrar's SWOG Roster ID Number
    Beskrivning

    RegistrarSouthwestOncologyGroupIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25699
    UMLS 2011AA Property-2
    C1519429
    NCI Thesaurus ObjectClass
    C25357
    UMLS 2011AA ObjectClass
    C0557514
    SWOG Investigator Number
    Beskrivning

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C17089
    UMLS 2011AA ObjectClass-2
    C0035173
    SWOG Treating Institution Number
    Beskrivning

    SouthwestOncologyGroupTreatingInstitutionIdentifierNumber

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    NCI Thesaurus ObjectClass-3
    C41206
    UMLS 2011AA ObjectClass-3
    C1272753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Unnamed5
    Beskrivning

    Unnamed5

    Date Informed Consent Signed (MM DD YYYY)
    Beskrivning

    InformedConsentFormSignedDate

    Datatyp

    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
    Date HIPAA Authorization signed (Not required if Country of Residence is not USA MM DD YYYY)
    Beskrivning

    HIPAA Approval Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0600593
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2346844
    NCI Thesaurus Property
    C25425
    Projected Start Date of Treatment (MM DD YYYY)
    Beskrivning

    Treatment Begin Date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C25631
    NCI Thesaurus Property
    C25431
    UMLS CUI-1
    C3173309
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    Stratification Question
    Beskrivning

    Stratification Question

    Baseline serum 25(OH)D level
    Beskrivning

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationS0812SerumType

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C25171
    UMLS 2011AA Property-2
    C0013893
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C13325
    UMLS 2011AA ValueDomain-2
    C0229671
    Baseline mammographic density
    Beskrivning

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationS0812MammogramType

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C25171
    UMLS 2011AA Property-2
    C0013893
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C20178
    UMLS 2011AA ValueDomain-2
    C0024671
    Designated biopsy site
    Beskrivning

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationS0812Type

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C25171
    UMLS 2011AA Property-2
    C0013893
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ValueDomain-2
    C20178
    UMLS 2011AA ValueDomain-2
    C0024671
    Unnamed4
    Beskrivning

    Unnamed4

    My blood may be kept for use in research to learn about, prevent, treat, or cure cancer
    Beskrivning

    BloodSpecimenMalignantNeoplasmRelatedResearchConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25648
    UMLS 2011AA Property
    C0439849
    NCI Thesaurus Property-3
    C9305
    UMLS 2011AA Property-2
    C0006826
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    My blood may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)
    Beskrivning

    BloodSpecimenOtherDiseasesandDisordersResearchConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C15319
    NCI Thesaurus Property-3
    C2991
    UMLS 2011AA Property-2
    C0012634
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Someone may contact me in the future to ask me to allow other uses of my blood
    Beskrivning

    PatientFutureCommunicationBloodSpecimenConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C67527
    UMLS 2011AA Property
    C0016884
    NCI Thesaurus Property-2
    C12434
    UMLS 2011AA Property-2
    C0229664
    NCI Thesaurus Property-3
    C19157
    UMLS 2011AA Property-3
    C0370003
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-4
    C1511481
    NCI Thesaurus Property-5
    C16452
    UMLS 2011AA Property-5
    C0009452
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer
    Beskrivning

    TissueSpecimenMalignantNeoplasmRelatedResearchConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12801
    UMLS 2011AA ObjectClass
    C0040300
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25648
    UMLS 2011AA Property
    C0439849
    NCI Thesaurus Property-3
    C9305
    UMLS 2011AA Property-2
    C0006826
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    My tissue may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)
    Beskrivning

    TissueSpecimenResearchConsentUnrelatedInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C12801
    UMLS 2011AA ObjectClass
    C0040300
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ValueDomain-2
    C25328
    UMLS 2011AA ValueDomain-2
    C0445356
    Someone may contact me in the future to ask me to allow other uses of my tissue
    Beskrivning

    PatientFutureCommunicationTissueSpecimenConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C67527
    UMLS 2011AA Property
    C0016884
    NCI Thesaurus Property-2
    C12801
    UMLS 2011AA Property-2
    C0040300
    NCI Thesaurus Property-3
    C19157
    UMLS 2011AA Property-3
    C0370003
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-4
    C1511481
    NCI Thesaurus Property-5
    C16452
    UMLS 2011AA Property-5
    C0009452
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    My mammogram may be kept for use in research to learn about, prevent, treat, or cure cancer
    Beskrivning

    PatientMammogramResearchActivityConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20178
    UMLS 2011AA Property
    C0024671
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus Property-3
    C15429
    UMLS 2011AA Property-3
    C0242481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    My mammogram may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)
    Beskrivning

    PatientMammogramResearchActivityOtherConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C20178
    UMLS 2011AA Property-2
    C0024671
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus Property-4
    C15429
    UMLS 2011AA Property-4
    C0242481
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Someone may contact me in the future to ask me to allow other uses of my mammogram
    Beskrivning

    PatientFutureCommunicationMammogramConsentInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C67527
    UMLS 2011AA Property
    C0016884
    NCI Thesaurus Property-2
    C20178
    UMLS 2011AA Property-2
    C0024671
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus Property-4
    C16452
    UMLS 2011AA Property-4
    C0009452
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    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
    Beskrivning

    SouthwestOncologyGroupPatientResearchConsentInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Unnamed 7
    Beskrivning

    Unnamed 7

    Has the SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?
    Beskrivning

    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C25171
    UMLS 2011AA Property-2
    C0013893
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Auxiliary Questions
    Beskrivning

    Auxiliary Questions

    Does the participant have a known deleterious mutation in BRCA1, BRCA2, PTEN or TP53
    Beskrivning

    KaryotypeDeletionMutationCellInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25215
    UMLS 2011AA ObjectClass
    C1261273
    NCI Thesaurus Property
    C12508
    UMLS 2011AA Property
    C0007634
    NCI Thesaurus Property-2
    C19296
    UMLS 2011AA Property-2
    C1511760
    Does the participant have a history of resected DCIS or LCIS
    Beskrivning

    DuctalBreastCarcinomaInSituLobularBreastCarcinomaInSituExcisionPersonalMedicalHistoryInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15232
    UMLS 2011AA ObjectClass
    C0728940
    NCI Thesaurus ObjectClass-2
    C2924
    UMLS 2011AA ObjectClass-2
    C0007124
    NCI Thesaurus ObjectClass-3
    C4018
    UMLS 2011AA ObjectClass-3
    C0279563
    NCI Thesaurus Property
    C18772
    UMLS 2011AA Property
    C0262926
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698

    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.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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)
    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)
    Item Group
    Stratification Question
    Item
    Baseline serum 25(OH)D level
    text
    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)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C13325 (NCI Thesaurus ValueDomain-2)
    C0229671 (UMLS 2011AA ValueDomain-2)
    Code List
    Baseline serum 25(OH)D level
    CL Item
    < 20 Ng/ml (1)
    CL Item
    20-32 Ng/ml (2)
    Item
    Baseline mammographic density
    text
    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)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20178 (NCI Thesaurus ValueDomain-2)
    C0024671 (UMLS 2011AA ValueDomain-2)
    Code List
    Baseline mammographic density
    CL Item
    11-50% (1)
    CL Item
    > 50% (2)
    Item
    Designated biopsy site
    text
    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)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20178 (NCI Thesaurus ValueDomain-2)
    C0024671 (UMLS 2011AA ValueDomain-2)
    Code List
    Designated biopsy site
    CL Item
    Yes (1)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (2)
    BloodSpecimenMalignantNeoplasmRelatedResearchConsentInd-3
    Item
    My blood may be kept for use in research to learn about, prevent, treat, or cure cancer
    boolean
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25648 (NCI Thesaurus Property-2)
    C0439849 (UMLS 2011AA Property)
    C9305 (NCI Thesaurus Property-3)
    C0006826 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    BloodSpecimenOtherDiseasesandDisordersResearchConsentInd-3
    Item
    My blood may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)
    boolean
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C15319 (NCI Thesaurus Property-2)
    C2991 (NCI Thesaurus Property-3)
    C0012634 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    PatientFutureCommunicationBloodSpecimenConsentInd-3
    Item
    Someone may contact me in the future to ask me to allow other uses of my blood
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C67527 (NCI Thesaurus Property)
    C0016884 (UMLS 2011AA Property)
    C12434 (NCI Thesaurus Property-2)
    C0229664 (UMLS 2011AA Property-2)
    C19157 (NCI Thesaurus Property-3)
    C0370003 (UMLS 2011AA Property-3)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-4)
    C16452 (NCI Thesaurus Property-5)
    C0009452 (UMLS 2011AA Property-5)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    TissueSpecimenMalignantNeoplasmRelatedResearchConsentInd-3
    Item
    My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer
    boolean
    C12801 (NCI Thesaurus ObjectClass)
    C0040300 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25648 (NCI Thesaurus Property-2)
    C0439849 (UMLS 2011AA Property)
    C9305 (NCI Thesaurus Property-3)
    C0006826 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    TissueSpecimenResearchConsentUnrelatedInd-3
    Item
    My tissue may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease)
    boolean
    C12801 (NCI Thesaurus ObjectClass)
    C0040300 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25328 (NCI Thesaurus ValueDomain-2)
    C0445356 (UMLS 2011AA ValueDomain-2)
    PatientFutureCommunicationTissueSpecimenConsentInd-3
    Item
    Someone may contact me in the future to ask me to allow other uses of my tissue
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C67527 (NCI Thesaurus Property)
    C0016884 (UMLS 2011AA Property)
    C12801 (NCI Thesaurus Property-2)
    C0040300 (UMLS 2011AA Property-2)
    C19157 (NCI Thesaurus Property-3)
    C0370003 (UMLS 2011AA Property-3)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-4)
    C16452 (NCI Thesaurus Property-5)
    C0009452 (UMLS 2011AA Property-5)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    PatientMammogramResearchActivityConsentInd-3
    Item
    My mammogram may be kept for use in research to learn about, prevent, treat, or cure cancer
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20178 (NCI Thesaurus Property)
    C0024671 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property-2)
    C15429 (NCI Thesaurus Property-3)
    C0242481 (UMLS 2011AA Property-3)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    PatientMammogramResearchActivityOtherConsentInd-3
    Item
    My mammogram 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)
    C20178 (NCI Thesaurus Property-2)
    C0024671 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C15429 (NCI Thesaurus Property-4)
    C0242481 (UMLS 2011AA Property-4)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    PatientFutureCommunicationMammogramConsentInd-3
    Item
    Someone may contact me in the future to ask me to allow other uses of my mammogram
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C67527 (NCI Thesaurus Property)
    C0016884 (UMLS 2011AA Property)
    C20178 (NCI Thesaurus Property-2)
    C0024671 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C16452 (NCI Thesaurus Property-4)
    C0009452 (UMLS 2011AA Property-4)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA 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)
    Item Group
    Unnamed 7
    SouthwestOncologyGroupPatientRegistrationEligibilityDeterminationInd-2
    Item
    Has the SWOG 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)
    Item Group
    Auxiliary Questions
    KaryotypeDeletionMutationCellInd-2
    Item
    Does the participant have a known deleterious mutation in BRCA1, BRCA2, PTEN or TP53
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25215 (NCI Thesaurus ObjectClass)
    C1261273 (UMLS 2011AA ObjectClass)
    C12508 (NCI Thesaurus Property)
    C0007634 (UMLS 2011AA Property)
    C19296 (NCI Thesaurus Property-2)
    C1511760 (UMLS 2011AA Property-2)
    DuctalBreastCarcinomaInSituLobularBreastCarcinomaInSituExcisionPersonalMedicalHistoryInd-2
    Item
    Does the participant have a history of resected DCIS or LCIS
    boolean
    C15232 (NCI Thesaurus ObjectClass)
    C0728940 (UMLS 2011AA ObjectClass)
    C2924 (NCI Thesaurus ObjectClass-2)
    C0007124 (UMLS 2011AA ObjectClass-2)
    C4018 (NCI Thesaurus ObjectClass-3)
    C0279563 (UMLS 2011AA ObjectClass-3)
    C18772 (NCI Thesaurus Property)
    C0262926 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)

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