Brain and Central Nervous System Tumors NCT00887146 Registration - North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form - 2745776v1.0
North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form Radiation Therapy or Radiation Therapy and Temozolomide or Temozolomide Alone in Treating Patients With Newly Diagnosed Anaplastic Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C096CEC-6180-47DB-E044-0003BA3F9857

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  1. StudyEvent: North Central Cancer Treatment Group N0577 Preregistration Screening Failure Form
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Protocol ID NCCTG
Item
Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1518419 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25581 (NCI Thesaurus Property-2)
PatientNorthCentralCancerTreatmentGroupIdentifierNumber
Item
Patient ID
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)
C25581 (NCI Thesaurus Property-2)
C1518419 (UMLS 2011AA Property-2)
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)
Institution Number
Item
Institution Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Institution Name
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Data amended
Item
Are data amended (If yes, highlight amended areas)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Preregistration Screening Failure
PriorRegistrationScreeningPatientClinicalTrialIneligibilityDate
Item
Date aware of preregistration screening failure (mm/dd/yyyy)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48261 (NCI Thesaurus ObjectClass-2)
C1710032 (UMLS 2011AA ObjectClass-2)
C25646 (NCI Thesaurus ObjectClass-3)
C1514821 (UMLS 2011AA ObjectClass-3)
C25629 (NCI Thesaurus ObjectClass-4)
C0332152 (UMLS 2011AA ObjectClass-4)
C15207 (NCI Thesaurus Property)
C40412 (NCI Thesaurus Property-2)
C1512714 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Primary reason screening failed (check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48261 (NCI Thesaurus ObjectClass-2)
C1710032 (UMLS 2011AA ObjectClass-2)
C25646 (NCI Thesaurus ObjectClass-3)
C1514821 (UMLS 2011AA ObjectClass-3)
C25629 (NCI Thesaurus ObjectClass-4)
C0332152 (UMLS 2011AA ObjectClass-4)
C15207 (NCI Thesaurus Property)
C40412 (NCI Thesaurus Property-2)
C1512714 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
Code List
Primary reason screening failed (check one)
CL Item
Investigator Decision (Investigator decision)
CL Item
Patient Decision (Patient decision)
CL Item
Did Not Meet Eligibility Criteria (Did not meet eligibility criteria)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PriorRegistrationScreeningPatientClinicalTrialIneligibilitySpecify
Item
Other, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48261 (NCI Thesaurus ObjectClass-2)
C1710032 (UMLS 2011AA ObjectClass-2)
C25646 (NCI Thesaurus ObjectClass-3)
C1514821 (UMLS 2011AA ObjectClass-3)
C25629 (NCI Thesaurus ObjectClass-4)
C0332152 (UMLS 2011AA ObjectClass-4)
C15207 (NCI Thesaurus Property)
C40412 (NCI Thesaurus Property-2)
C1512714 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)