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9262

Description

ANBL0321: On Study Worksheet Fenretinide in Treating Children With Recurrent or Resistant Neuroblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9543982-264A-44CD-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9543982-264A-44CD-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Neuroblastoma NCT00053326 On-Study - ANBL0321: On Study Worksheet - 2087047v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: ANBL0321: On Study Worksheet
      1. No Instruction available.
    Header
    Description

    Header

    Name
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Study Number
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    Study Number
    Description

    Protocol ID COG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516477
    NCI Thesaurus Property
    C25364
    COG Number
    Description

    PatientCOGIdentifierNumber

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C39353
    UMLS 2011AA Property-2
    C1516477
    Patient Initials
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Today's date
    Description

    Form Completion Date

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C1549507
    NCI Thesaurus Property
    C25250
    NCI Thesaurus Property-2
    C25604
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Date worksheet entered into RDE
    Description

    DataEnteredDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C37949
    UMLS 2011AA Property
    C1521975
    Unnamed2
    Description

    Unnamed2

    Accession number (Pre-populated by the registration system.)
    Description

    SpecimenAccessionNumber

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25402
    UMLS 2011AA Property
    C1510755
    Stratum (Pre-populated by the registration system.)
    Description

    StudyStratificationText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15206
    UMLS 2011AA ObjectClass
    C0008972
    NCI Thesaurus Property
    C25689
    UMLS 2011AA Property
    C1514983
    Treatment Number (Pre-populated by the registration system.)
    Description

    Protocol Treatment Arm

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1522541
    NCI Thesaurus Property
    C32141
    NCI Thesaurus ObjectClass
    C15368
    Treating Institution (Pre-populated by the registration system.)
    Description

    TreatingInstitutionIdentifierCode

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    Treating Physician (Pre-populated by the registration system.)
    Description

    TreatingPhysicianName

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25741
    UMLS 2011AA ObjectClass
    C0031831
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    Date of Randomization (Pre-populated by the registration system.)
    Description

    ProtocolRandomizationDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25196
    UMLS 2011AA Property
    C0034656
    Date of call back (Pre-populated by the registration system.)
    Description

    PatientCallbackDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    Date of Registration (Pre-populated by the registration system.)
    Description

    PatientRegistrationDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    Treatment Start Date (Pre-populated by the registration system.)
    Description

    Treatment Begin Date

    Data type

    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
    Method of Payment
    Description

    PatientPaymentType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25371
    UMLS 2011AA Property
    C0680264
    Date of original diagnosis (1. Required field)
    Description

    CancerInitialDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    Was biopsy of tumor site done to confirm active tumor for study eligibility? (1. Required field)
    Description

    TumorBiopsyInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C15189
    UMLS 2011AA Property
    C0005558
    list site(s) [biopsy of tumor site(s)] (and submit pathology reports from biopsy sites to the RDC)
    Description

    NeuroblastomaBiopsySite

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    Other, specify [biopsy of tumor site(s)]
    Description

    NeuroblastomaBiopsySiteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    Scans done at study entry (Check on all study scans and submit reports to the RDC)
    Description

    TumorScanType

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C17999
    UMLS 2011AA Property
    C0441633
    Other, specify [scans done at study entry]
    Description

    TumorScanSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C17999
    UMLS 2011AA Property
    C0441633
    Unnamed3
    Description

    Unnamed3

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Ccrr Module For Anbl0321: On Study Worksheet
    Description

    Ccrr Module For Anbl0321: On Study Worksheet

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    1 forms
    1. StudyEvent: ANBL0321: On Study Worksheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Institution Name
    Item
    Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Protocol ID COG
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516477 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    PatientCOGIdentifierNumber
    Item
    COG Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C39353 (NCI Thesaurus Property-2)
    C1516477 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Today's date
    date
    C19464 (NCI Thesaurus ObjectClass)
    C1549507 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C25604 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    DataEnteredDate
    Item
    Date worksheet entered into RDE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C37949 (NCI Thesaurus Property)
    C1521975 (UMLS 2011AA Property)
    Item Group
    Unnamed2
    SpecimenAccessionNumber
    Item
    Accession number (Pre-populated by the registration system.)
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25402 (NCI Thesaurus Property)
    C1510755 (UMLS 2011AA Property)
    StudyStratificationText
    Item
    Stratum (Pre-populated by the registration system.)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15206 (NCI Thesaurus ObjectClass)
    C0008972 (UMLS 2011AA ObjectClass)
    C25689 (NCI Thesaurus Property)
    C1514983 (UMLS 2011AA Property)
    Protocol Treatment Arm
    Item
    Treatment Number (Pre-populated by the registration system.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1522541 (UMLS CUI-1)
    C32141 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    TreatingInstitutionIdentifierCode
    Item
    Treating Institution (Pre-populated by the registration system.)
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    TreatingPhysicianName
    Item
    Treating Physician (Pre-populated by the registration system.)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25741 (NCI Thesaurus ObjectClass)
    C0031831 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    ProtocolRandomizationDate
    Item
    Date of Randomization (Pre-populated by the registration system.)
    date
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25196 (NCI Thesaurus Property)
    C0034656 (UMLS 2011AA Property)
    PatientCallbackDate
    Item
    Date of call back (Pre-populated by the registration system.)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    PatientRegistrationDate
    Item
    Date of Registration (Pre-populated by the registration system.)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    Treatment Begin Date
    Item
    Treatment Start Date (Pre-populated by the registration system.)
    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
    Method of Payment
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25371 (NCI Thesaurus Property)
    C0680264 (UMLS 2011AA Property)
    CL.1
    Code List
    Method of Payment
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Military Or Veterans Sponsored Nos (Military or Veterans sponsored NOS)
    CL Item
    Military Sponsored (including Champus & Tricare) (Military sponsored (including CHAMPUS and 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
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CancerInitialDiagnosisDate
    Item
    Date of original diagnosis (1. Required field)
    date
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    TumorBiopsyInd-3
    Item
    Was biopsy of tumor site done to confirm active tumor for study eligibility? (1. Required field)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C15189 (NCI Thesaurus Property)
    C0005558 (UMLS 2011AA Property)
    Item
    list site(s) [biopsy of tumor site(s)] (and submit pathology reports from biopsy sites to the RDC)
    text
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    CL.3
    Code List
    list site(s) [biopsy of tumor site(s)] (and submit pathology reports from biopsy sites to the RDC)
    CL Item
    Bone Lesion (Bone lesion)
    CL Item
    Soft Tissue Lesion (Soft tissue lesion)
    CL Item
    Bone Marrow Aspirate (Bone marrow aspirate)
    CL042344 (NCI Metathesaurus)
    CL Item
    Bone Marrow Biopsy (Bone marrow biopsy)
    C15193 (NCI Thesaurus)
    C0005954 (UMLS 2011AA)
    CL Item
    Other, Specify (Other, specify)
    NeuroblastomaBiopsySiteSpecify
    Item
    Other, specify [biopsy of tumor site(s)]
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    Item
    Scans done at study entry (Check on all study scans and submit reports to the RDC)
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C17999 (NCI Thesaurus Property)
    C0441633 (UMLS 2011AA Property)
    CL.4
    Code List
    Scans done at study entry (Check on all study scans and submit reports to the RDC)
    CL Item
    Ct Scan (CT)
    CL Item
    Mri (MRI)
    CL Item
    Mibg (MIBG)
    CL Item
    Bone Scan (Bone scan)
    C17646 (NCI Thesaurus)
    C0203668 (UMLS 2011AA)
    CL Item
    Other, Specify (Other, specify)
    TumorScanSpecify
    Item
    Other, specify [scans done at study entry]
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C17999 (NCI Thesaurus Property)
    C0441633 (UMLS 2011AA Property)
    Item Group
    Unnamed3
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    Ccrr Module For Anbl0321: On Study Worksheet
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