Instructions: Answer all questions and explain any blank fields or blank dates in the Notes section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
Most Recent SWOG Study No.
text
Patient Initials
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
float
PatientStudyID,ParticipatingGroup
Item
Pt. ID
text
Item Group
Date of death
DeathDate/LastContactDate
Item
Date of Death (month / day / year)
date
Item Group
Causes Of Death
Item
Any cancer (select one)
text
CL.1
Code List
Any cancer (select one)
CL Item
No2005686 (No)
CL Item
Primary_cause2005687 (Primary Cause)
CL Item
Contributory2005688 (Contributory)
CL Item
Possible2005689 (Possible)
CL Item
Unknown2005690 (Unknown)
Item
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
If cancer was the primary cause or if cancer possibly or definitely contributed to death, and the patient had had multiple tumor types, specify those which were causes of death
CL Item
Cancer_of_most_recent_s2005692 (Cancer of most recent SWOG study, specify cancer)
CL Item
Cancer_of_oth_swog_stdy2005693 (Cancer of other SWOG study, specify cancer)
CL Item
Other_cancer_specify2005694 (Other cancer, specify)
SouthwestOncologyGroupMalignantNeoplasmMostRecentProtocolSpecify
Item
Cancer of most recent SWOG study, specify cancer
text
C25699 (NCI Thesaurus ObjectClass)
C1519429 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25320 (NCI Thesaurus Property)
C1507394 (UMLS 2011AA Property)
C25577 (NCI Thesaurus Property-2)
C1513491 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
CancerofotherSWOGstudy,specifycancer
Item
Cancer of other SWOG study, specify cancer
text
Othercancer,specify
Item
Other cancer, specify
text
Item
Toxicity from disease related treatment (select one)
text
CL.3
Code List
Toxicity from disease related treatment (select one)
CL Item
No2005697 (No)
CL Item
Primary_cause2005698 (Primary Cause)
CL Item
Contributory2005699 (Contributory)
CL Item
Possible2005700 (Possible)
CL Item
Unknown2005701 (Unknown)
IfPrimaryCause,ContributoryorPossible,specifytreatmentandtoxicity
Item
If Primary Cause, Contributory or Possible, specify treatment and toxicity
text
Item
Non-cancer and non-treatment related causes (select one)
text
CL.4
Code List
Non-cancer and non-treatment related causes (select one)
CL Item
No2005705 (No)
CL Item
Primary_cause2005706 (Primary Cause)
CL Item
Contributory2005707 (Contributory)
CL Item
Possible2005708 (Possible)
CL Item
Unknown2005709 (Unknown)
IfPrimaryCause,ContributoryorPossible,specify
Item
If Primary Cause, Contributory or Possible, specify
text
Item
Autopsy done?
text
CL.5
Code List
Autopsy done?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Death information obtained from (select all that apply)
text
CL.6
Code List
Death information obtained from (select all that apply)
CL Item
Autopsy Was The Source Of Information On The Patient's Death (Autopsy report)
CL Item
Death Certificate Was The Source Of Information On The Patient's Death (Medical record / Death certificate)
CL Item
Clinical Evidence Was The Source Of Information On The Patient's Death (Physician)
CL Item
Relative or friend (Relative or friend)
CL Item
The Source Of Information On The Patient's Death Is Not On This List, Specify Other (Other, specify)
Other,specify(deathinformationobtained)
Item
Other, specify
text
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For Southwest Oncology Group Notice Of Death (s0227)
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