NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104)
NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9BED937-4416-2507-E034-0003BA12F5E7

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  1. StudyEvent: NCI COOPERATIVE GROUP Patient Information FORM (CALGB-90104
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Mskcc 00-138; Calgb-90104; Ecog
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Afiiliate
text
RegisteredInvestigator
Item
Physician of Record
text
Item Group
Protocol Administration
IRB/REBApprovalDate
Item
IRB/REB Approval Date
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InformedConsentDateSigned
Item
Date Informed Consent Signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PersonCompletingForm,Phone
Item
Person Completing Form, Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
PersonCompletingForm,Fax
Item
Person Completing Form, Fax
float
ProjectedTreatmentBeginDate
Item
Projected Start Date of Treatment
date
RegistrationDate
Item
Date of Registration
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Patient Demographics / Pre-treatment Characteristics
PatientName,Last
Item
Patient Name, Last (initials acceptable)
text
PatientName,First
Item
Patient Name, First (initials acceptable)
text
PatientName,Middle
Item
Patient Name, Middle (initials acceptable)
text
PatientBirthDate
Item
Patient Birth Date (MM DD YYYY)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
Patient Gender
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
Code List
Patient Gender
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
Item
Patient Race/Ethnicity (check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
Code List
Patient Race/Ethnicity (check one)
CL Item
White_cdus (White, not of Hispanic origin)
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race (Hispanic)
CL Item
Black_cdus (Black, not of Hispanic origin)
CL Item
Pacific_islander_cdus (Native Hawaiian or other Pacific Islander)
CL Item
Asian_cdus (Asian)
CL Item
Native_american_cdus (Native North American)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientSocialSecurityNumber
Item
Patient Social Security Number
float
Address,Line1
Item
Street Address
text
Address,City
Item
City
text
Address,StateCode
Item
State
text
PatientAddress,PostalCode
Item
Patient?s ZIP Code (USA)
float
PatientAddress,Country
Item
Country of Residence (if not USA)
text
PatientHeight
Item
Patient Height (cm)
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
PatientWeight
Item
Patient Weight (kg)
float
BodySurfaceArea
Item
Body Surface Area
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item
Performance Status (check one)
text
Code List
Performance Status (check one)
CL Item
0 (Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90 - 100))
C0919414 (NCI Metathesaurus)
CL Item
1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
CL Item
2 (Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50 - 60))
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (K 30 - 40))
CL Item
4 (Completely disabled (K 10 - 20))
Item Group
Certification Of Eligibility
PatientEligibilityInd
Item
In the opinion of the investigator is the patient eligible?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25171 (NCI Thesaurus Property)
C0013893 (UMLS 2011AA Property)
Item Group
Protocol Design
Item
Primary Tumor Pathological Stage
text
Code List
Primary Tumor Pathological Stage
CL Item
Tumor Invades Subepithelial Connective Tissue (T1)
CL Item
Tumor Invades Superficial Muscles (inner Half) (T2)
CL Item
Tumor Invades Perivesical Tissue Microscopically (T3)
CL Item
Inflammatory Carcinoma (T4)
C0334385 (NCI Metathesaurus)
Item
Number of Nodes Involved By Tumor (check one)
text
Code List
Number of Nodes Involved By Tumor (check one)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1/5/2002 (1/5/2002)
CL Item
>=6 (>=6)
CL Item
A (A)
C14653 (NCI Thesaurus)
CL Item
B (B)
Item Group
Initial Patient Consent For Specimen Use
PatientInitialConsent,Specimen,Patient'scancerresearchInd
Item
Patient?s Initial Consent given for specimen use for research on the patient?s cancer?
boolean
PatientInitialConsent,Specimen,Researchunrelatedtopatient'scancerInd
Item
Patient?s Initial Consent given for specien use for research unrelated to the patient?s cancer?
boolean
PatientInitialConsent,Specimen,ContactInd
Item
Patient?s Initial Consent given for further contact regarding specimen?
boolean
InformedConsentDateSigned,SpecimenUse
Item
Date of Consent for Specimen Use (MM DD YYYY)
date