INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
CALGB Form
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
Protocol ID CALGB
Item
CALGB Study No
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Data amended
Item
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Patient demographics
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientHospitalNumber
Item
Patient Hospital No
text
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Participating Group
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI [1])
Item Group
Patient Characteristics
Post menopausal
Item
Post menopausal
boolean
C25180 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C15421 (NCI Thesaurus Property)
C0232970 (UMLS CUI [1])
GnRH-A agonist
Item
Is patient on ovarian suppression with GnRH-A agonist
boolean
C15445 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C2270 (NCI Thesaurus Property-2)
C1514 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1518041 (UMLS CUI [1])
Item Group
Disease Description
Item
ER status (Mark one with an X.)
text
C3262 (NCI Thesaurus ValueDomain)
C0027651 (UMLS 2011AA ValueDomain)
C17069 (NCI Thesaurus ObjectClass)
C0034804 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain-2)
C0449438 (UMLS 2011AA ValueDomain-2)
C25554 (NCI Thesaurus Property)
C0441889 (UMLS 2011AA Property)
CL.4
Code List
ER status (Mark one with an X.)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ERAssayPerformedTime
Item
Other, specify
text
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C17069 (NCI Thesaurus ObjectClass)
C0034804 (UMLS 2011AA ObjectClass)
C16341 (NCI Thesaurus ObjectClass-2)
C0005507 (UMLS 2011AA ObjectClass-2)
Item
PgR status (Mark one with an X.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0034833 (UMLS 2011AA ObjectClass)
C0678257 (NCI Metathesaurus Property)
CL.6
Code List
PgR status (Mark one with an X.)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Timing of assay (Mark one with an X.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25452 (NCI Thesaurus ValueDomain-2)
C17220 (NCI Thesaurus ObjectClass)
C0041365 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
CL.7
Code List
Timing of assay (Mark one with an X.)
CL Item
Initial Diagnosis (Initial diagnosis)
CL Item
At Recurrence (At recurrence)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Timing of assay (Mark one with an X.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25452 (NCI Thesaurus ValueDomain-2)
C17220 (NCI Thesaurus ObjectClass)
C0041365 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
CL.7
Code List
Timing of assay (Mark one with an X.)
CL Item
Initial Diagnosis (Initial diagnosis)
CL Item
At Recurrence (At recurrence)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PgRAssayPerformedTime
Item
Other, specify
text
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0034833 (UMLS 2011AA ObjectClass)
C16341 (NCI Thesaurus ObjectClass-2)
C0005507 (UMLS 2011AA ObjectClass-2)
Diagnosis date
Item
Date of initial diagnosis of primary tumor
date
C15189 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus ObjectClass-2)
C25246 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C2316983 (UMLS CUI [1])
DiseaseRecurrenceDate
Item
Date progressive or metastatic disease first diagnosed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C3352 (NCI Thesaurus Property)
C0034897 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Item Group
Site Of Progression Or Recurrence
Item
Site of progression (s)
text
C13717 (NCI Thesaurus ValueDomain)
C0242656 (UMLS CUI-1)
C25341 (NCI Thesaurus Property)
C1515974 (UMLS CUI-2)
C25331 (NCI Thesaurus ObjectClass)
CL.8
Code List
Site of progression (s)
CL Item
Local-regional (including Ipsilateral Breast; Chest Wall; Axillary, Internal Mammary, And Infraclavicular Nodes; Local-regional Skin And Subcutaneous Tissue) (Local-regional)
CL Item
Ipsilateral Supraclavicular Nodes (Ipsilateral supraclavicular nodes)
CL Item
Contralateral Breast (Opposite breast)
CL Item
Distant Lymph Nodes (Distant nodes)
CL Item
Distant Skin/subcutaneous Tissue (Distant skin/subcutaneous skin)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Bone Marrow (Bone marrow)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Lung, Nos (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Pleura (Pleura)
C12469 (NCI Thesaurus)
C0032225 (UMLS 2011AA)
CL Item
Brain (Brain)
C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)
CL Item
Other Cns (Other CNS)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
C17649 (NCI Thesaurus-3)
C0205394 (UMLS 2011AA-4)
Progression Site, specify
Item
Other, specify:
text
C25685 (NCI Thesaurus ValueDomain)
C0242656 (UMLS CUI-1)
C25341 (NCI Thesaurus Property)
C1515974 (UMLS CUI-2)
C25331 (NCI Thesaurus ObjectClass)
Item Group
Prior Systemic Therapy
AdjuvantHormonalTherapyPriorAdministeredInd-3
Item
Prior adjuvant hormonal therapy (Do not include steroids given with chemotherapy.)
boolean
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C0001552 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Prior endocrine therapy for metastasis or recurrence
Item
Prior endocrine therapy for metastasis or recurrence (Do not include steroids given with chemotherapy.)
boolean
C25629 (NCI Thesaurus ObjectClass)
C15445 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
C25567 (NCI Thesaurus Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1514463 (UMLS CUI [1,1])
C0279025 (UMLS CUI [1,2])
PriorChemotherapyAdministeredInd-3
Item
Prior adjuvant chemotherapy (Include pre-op chemotherapy at diagnosis.)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Prior chemotherapy for metastasis or recurrence
Item
Prior chemotherapy for metastasis or recurrence
boolean
C15632 (NCI Thesaurus ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C14174 (NCI Thesaurus Property)
C38155 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C0392920 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
PriorHDC/ASCTAdjuvantAdministeredInd-3
Item
Prior adjuvant high dose chemotherapy/Autologous stem cell transplant (HDC/ASCT )
boolean
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C38722 (NCI Thesaurus ObjectClass-2)
C1512429 (UMLS 2011AA ObjectClass-2)
C2140 (NCI Thesaurus Property)
C0001552 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Prior HDC/ASCT for metastasis or recurrence
Item
Prior High-Dose Chemotherapy with Autologous Stem Cell Transplant for metastasis or recurrence
boolean
C25629 (NCI Thesaurus ObjectClass)
C38722 (NCI Thesaurus ObjectClass-2)
C14174 (NCI Thesaurus Property)
C38155 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512429 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
Prior adjuvant immunotherapy
Item
Prior adjuvant immunotherapy
boolean
C15262 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C25629 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1514455 (UMLS CUI [1])
Prior immunotherapy for metastasis or recurrence
Item
Prior immunotherapy for metastasis or recurrence
boolean
C15262 (NCI Thesaurus ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C14174 (NCI Thesaurus Property)
C38155 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C0021083 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
Prior adjuvant other therapy
Item
Prior adjuvant other therapy
boolean
C15368 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C17649 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C38148 (NCI Thesaurus ValueDomain)
C25629 (NCI Thesaurus ValueDomain-2)
C1514456 (UMLS CUI [1])
Prior other adjuvant therapy
Item
Prior other adjuvant therapy
text
C15368 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C17649 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1514456 (UMLS CUI [1])
Prior other therapy for metastasis or recurrence
Item
Prior other therapy for metastasis or recurrence
boolean
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C14174 (NCI Thesaurus Property)
C38155 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C17649 (NCI Thesaurus ValueDomain)
C38148 (NCI Thesaurus ValueDomain-2)
C1514463 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
Prior therapy for metastatic or recurrent disease
Item
Prior therapy for metastatic or recurrent disease
text
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C14174 (NCI Thesaurus Property)
C38155 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1514463 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
Item Group
Prior Systemic Regimens
PriorTreatmentRegimenName
Item
Prior treatment regimen name (s)
text
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
Treatment start date
Item
Start date
date
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI [1])
Treatment end date
Item
End date
date
C25164 (NCI Thesaurus ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C1531784 (UMLS CUI [1])
Item
Prior treatment regimen type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
CL.19
Code List
Prior treatment regimen type
CL Item
Adjuvant (Adjuvant)
C25722 (NCI Thesaurus)
C1522673 (UMLS 2011AA)
CL Item
Advanced (Advanced)
C25411 (NCI Thesaurus)
C0205179 (UMLS 2011AA)
Item Group
Required Laboratory Values
C0022885 (UMLS CUI-1)
Granulocyte count
Item
Granulocytes
float
C20200 (NCI Thesaurus Property)
C12530 (NCI Thesaurus Property-2)
C25463 (NCI Thesaurus ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
C0857490 (UMLS CUI [1])
Platelets
Item
Platelet count
float
C20200 (NCI Thesaurus Property)
C0005821 (UMLS CUI-1)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
Creatinine, Serum
Item
Creatinine
float
C25225 (NCI Thesaurus ObjectClass)
C399 (NCI Thesaurus Property)
C25294 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C0201976 (UMLS CUI [1])
Bilirubin, total
Item
Bilirubin, total
float
C20200 (NCI Thesaurus Property)
C305 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0201913 (UMLS CUI [1])
Bilirubin ULN
Item
Bilirubin ULN
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C305 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0005437 (UMLS CUI [1,1])
C1519815 (UMLS CUI [1,2])
ALT
Item
ALT (SGPT)
float
C20200 (NCI Thesaurus Property)
C25294 (NCI Thesaurus ObjectClass)
C25293 (NCI Thesaurus Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0201836 (UMLS CUI [1])
ALT ULN
Item
ALT (SGPT) ULN
float
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C25293 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0376147 (UMLS CUI [1,1])
C1519815 (UMLS CUI [1,2])
AST
Item
AST (SGOT)
float
C13308 (NCI Thesaurus ObjectClass)
C25202 (NCI Thesaurus Property)
C38046 (NCI Thesaurus ValueDomain)
C37984 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain-2)
C0201899 (UMLS CUI [1])
AST ULN
Item
AST (SGOT) ULN
float
C25294 (NCI Thesaurus ObjectClass)
C25202 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C0242192 (UMLS CUI [1,1])
C1519815 (UMLS CUI [1,2])
Item
Was tumor marker information available for the following (Mark all that apply with an X.)
integer
C25284 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus Property)
C17220 (NCI Thesaurus ObjectClass)
C25429 (NCI Thesaurus Property-2)
C0041365 (UMLS CUI [1])
CL.20
Code List
Was tumor marker information available for the following (Mark all that apply with an X.)
CL Item
CEA (1)
C0201933 (UMLS CUI-1)
CL Item
CA 15-3 (2)
C0201547 (UMLS CUI-1)
CL Item
CA 27-29 (3)
C2919221 (UMLS CUI-1)
CEA
Item
Carcinoembryonic Antigen
float
C25159 (NCI Thesaurus Property)
C25294 (NCI Thesaurus Property-2)
C17220 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0201933 (UMLS CUI [1])
CA 15-3
Item
CA 15-3
float
C25294 (NCI Thesaurus ValueDomain)
C17220 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain-2)
CL122032 (NCI Metathesaurus Property)
C0201547 (UMLS CUI [1])
CA 27-29
Item
CA 27-29
float
C25294 (NCI Thesaurus Property)
C17220 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0291672 (NCI Metathesaurus Property)
C2919221 (UMLS CUI [1])
Person Completing Form
Item
Completed by
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Date Form Completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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