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  1. StudyEvent: S0100 Registration Form-1
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Consent For Specimen Use
C0370003 (UMLS CUI-1)
C0021430 (UMLS CUI-2)
C0035168 (UMLS CUI-3)
tissue for research
Item
Patient's tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
boolean
C0370003 (UMLS CUI [1,1])
C0035168 (UMLS CUI [1,2])
tissue for research
Item
Patient's tissue may be kept for research about other health problems
boolean
C0370003 (UMLS CUI [1,1])
C0035168 (UMLS CUI [1,2])
contact patient
Item
Someone from the Southwest Oncology Group may contact the patient in the future to ask him or her to take part in more research.
boolean
C0332158 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
Birth Date
Item
Patient's Date of Birth
date
C16960 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0421451 (UMLS CUI [1])
Item
Patient's Sex
integer
C25372 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI [1])
Code List
Patient's Sex
CL Item
Female (1)
CL Item
Male (2)
Item
Method of Payment
text
Code List
Method of Payment
CL Item
Private Insurance (Private)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare and Private)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Self Pay (no Insurance) (No insurance (self-pay))
CL Item
No Means Of Payment (no Insurance) (No insurance (no means))
CL Item
Other (Other, specify at registration)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Sponsored (Veterans Admin)
CL Item
Military Sponsored (including Champus & Tricare) (Military)
Item
Patient's Ethnicity
integer
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0015031 (UMLS CUI [1])
Code List
Patient's Ethnicity
CL Item
Unknown (1)
C0439673 (UMLS CUI-1)
(Comment:en)
CL Item
No (not Spanish) (2)
(Comment:en)
CL Item
Yes, Mexican (3)
(Comment:en)
CL Item
Yes,Puerto Rican (4)
(Comment:en)
CL Item
Yes, Cuban (5)
(Comment:en)
CL Item
Yes, Central American (6)
(Comment:en)
CL Item
Yes, South American (7)
(Comment:en)
CL Item
Yes,Other (8)
(Comment:en)
CL Item
Yes, NOS (9)
(Comment:en)
CL Item
Hispanic_or_latino (10)
(Comment:en)
CL Item
Non_hispanic (11)
(Comment:en)
Item
Patient's Race
text
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS CUI [1])
Code List
Patient's Race
CL Item
White or Caucasian (1)
(Comment:en)
CL Item
Black or African American (2)
(Comment:en)
CL Item
Native Hawaiian or Other Pacific Islander (3)
(Comment:en)
CL Item
Asian (4)
(Comment:en)
CL Item
American Indian or Alaska Native (5)
(Comment:en)
CL Item
Unknown (6)
C0439673 (UMLS CUI-1)
(Comment:en)
CL Item
Other (7)
(Comment:en)
Race Other
Item
specify
text
C25685 (NCI Thesaurus ValueDomain)
C0034510 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Patient's Social Security Number
Item
Patient's Social Security Number
text
C1301821 (UMLS CUI [1])
Patient's ZIP Code
Item
Patient's ZIP Code
integer
C0421454 (UMLS CUI [1])
Country of Residence
Item
Country of Residence, if not USA
text
C1562954 (UMLS CUI [1])
Social Insurance Number
Item
Social Insurance Number
text
C16960 (NCI Thesaurus ObjectClass)
C62650 (NCI Thesaurus ObjectClass-2)
C16745 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C0728831 (UMLS CUI [1,1])
C0021672 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Postal Code
Item
Postal Code
text
C25162 (NCI Thesaurus ValueDomain)
C25407 (NCI Thesaurus ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS CUI [1])
Item Group
Stratification Factors
C1514984 (UMLS CUI-1)
Patient Age
Item
Age
float
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS CUI [1])
Item
Phenotype
integer
C0031437 (UMLS CUI [1,1])
C1961099 (UMLS CUI [1,2])
C1292769 (UMLS CUI [1,3])
Code List
Phenotype
CL Item
T-cell (1)
CL Item
Pre-b (2)
Comments
Item
Notes
text
C0947611 (UMLS CUI [1,1])
C1514984 (UMLS CUI [1,2])
Item Group
Ccrr Module For S0100 Registration Form-1
C1514821 (UMLS CUI-1)
Study Number
Item
SWOG Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI-1)
Protocol Treatment Arm
Item
Assigned Treatment Arm
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C32141 (NCI Thesaurus Property)
C25426 (NCI Thesaurus Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1522541 (UMLS CUI [1])
Activation Date
Item
Activation Date
date
C25320 (NCI Thesaurus ObjectClass)
C64382 (NCI Thesaurus Property)
C41200 (NCI Thesaurus Property-2)
C1879547 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1507394 (UMLS CUI [1,3])
Last Amended Date
Item
Last Amended Date
date
C25164 (NCI Thesaurus ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C25551 (NCI Thesaurus ValueDomain-2)
C1691222 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Patient's Name
Item
Patient's Name
text
C1299487 (UMLS CUI [1])
Patient ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Caller's SWOG Roster ID
Item
Caller's SWOG Roster ID
text
C25337 (NCI Thesaurus ValueDomain)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
C25357 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
SWOG Treating Institution Number
Item
SWOG Treating Institution Number
text
C25699 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C41206 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C1519429 (UMLS CUI [1,1])
C1272753 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,3])
Date Informed Consent Signed
Item
Date Informed Consent Signed
text
C0021430 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator
Item
SWOG Investigator Number
text
C2826892 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
IRB Approval Date
Item
IRB Approval Date
date
C25320 (NCI Thesaurus ObjectClass)
C25425 (NCI Thesaurus Property)
C1507394 (UMLS CUI [1,1])
C0205540 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Projected Start Date of Treatment
Item
Projected Start Date of Treatment
date
C3173309 (UMLS CUI [1])

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