ID

10057

Description

A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2 Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer NCT00023829 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CB05D-071D-28BA-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CB05D-071D-28BA-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 3/22/15 3/22/15 - Martin Dugas
Uploaded on

March 22, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer RTOG NCT00023829

English

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling boxes or blanks as requested. See separate page for instructions

1 forms  
Header
Description

Header

Date Completed (mm/dd/yyyy)
Description

DateCompleted

Data type

date

RTOG Study
Description

RTOGStudy

Data type

text

Case #
Description

Case#

Data type

text

Institution
Description

Institution

Data type

text

Institution #
Description

Institution#

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Name
Description

PatientName

Data type

text

Patient ID # (10. Family History)
Description

PatientID#

Data type

text

If this is a revised or corrected form, indicate by checking box. (1.)
Description

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Data type

boolean

Who completed this form? (Check one box)
Description

Whocompletedthisform?

Data type

text

Patient characteristics
Description

Patient characteristics

Race (Check one box only)
Description

PatientRace

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Other, specify (race) (2B.)
Description

Other,specify(race)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Description

AdditionalRace/Ethnicity

Data type

text

Highest school grade completed (Check one box)
Description

Highestschoolgradecompleted

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property-2
C25525
UMLS 2011AA Property-2
C1522410
Other, specify (highest school grade completed) (4.)
Description

Other,specify(highestschoolgradecompleted)

Data type

text

Religion during childhood (Check one box)
Description

PersonPediatricReligionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property-2
C17085
UMLS 2011AA Property-2
C0035039
Other, specify (religion during childhood) (5.)
Description

Other,specify(religionduringchildhood)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Marital status (Check one box)
Description

Maritalstatus

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Where were you born? (Check one box)
Description

Wherewereyouborn?

Data type

text

USA, specify the 2 letter State code, eg NY
Description

USA,specifythe2letterStatecode,egNY

Data type

text

Other country, specify (where you were born) (7.)
Description

Othercountry,specify(whereyouwereborn)

Data type

text

Where did you live the longest (Check one box)
Description

Wheredidyoulivethelongest

Data type

text

Other country, specify (where you lived the longest) (8. Cigarette History?)
Description

Othercountry,specify(whereyoulivedthelongest)

Data type

text

Smoked at least 100 cigarette (5 packs) during lifetime (B.)
Description

Smoking history

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1519384
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C29719
Age began smoking cigarettes (C.)
Description

PatientInitialCigaretteSmokingAgeYearCount

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NCI Thesaurus Property-2
C18270
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
UMLS CUI-1
C0453999
Number of years smoked cigarettes (D.)
Description

Numberofyearssmokedcigarettes

Data type

integer

Alias
UMLS CUI-1
C3260576
Average number of cigarettes smoked per day (E.)
Description

Averagenumberofcigarettessmokedperday

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3694146
If quit, age stopped smoking completely
Description

PatientSmokingCessationAgeYear

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
NCI Metathesaurus Property
C0085134
UMLS CUI-1
C3172720
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
Description

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Data type

text

Alias
UMLS CUI-1
C0683519
Specify other (illness)
Description

Specifyother(illness)

Data type

text

Family history
Description

Family history

Alias
UMLS CUI-1
C0241889
Brothers
Description

Brothers

Data type

text

Alias
UMLS CUI-1
C0337527
Sisters
Description

Sisters

Data type

text

Alias
UMLS CUI-1
C0337514
Sons
Description

Sons

Data type

text

Alias
UMLS CUI-1
C0037683
Daughters (B.)
Description

Daughters (B.)

Data type

text

Alias
UMLS CUI-1
C0011011
Are you adopted? (Check one)
Description

Are you adopted? (Check one)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25290
UMLS CUI-1
C0425382
Blood relative with cancer
Description

Bloodrelativewithcancer

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0260515
Age when first cancer diagnosed
Description

PersonFirstCancerDiagnosisAgeYearCount

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus Property
C9305
NCI Thesaurus Property-2
C25509
NCI Thesaurus Property-3
C15220
NCI Thesaurus Property-4
C25150
NCI Thesaurus ValueDomain
C29848
NCI Thesaurus ValueDomain-2
C25463
UMLS CUI-1
C3172271
Type of Cancer
Description

TypeofCancer

Data type

text

Alias
UMLS CUI-1
C0872066
specify (other cancers) (11A.)
Description

specify(othercancers)

Data type

text

Cancer prevention trial
Description

Cancer prevention trial

Have you ever heard of Cancer Prevention Trials? (Check one box)
Description

CancerPreventionTrialKnowledgeDocumentedInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C15790
NCI Thesaurus Property
C25356
NCI Metathesaurus Property
C0376554
UMLS CUI-1
C1516220
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
Description

CancerPreventionTrialParticipationScale

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25664
NCI Thesaurus Property
C25608
NCI Thesaurus ObjectClass
C15790
UMLS CUI-1
C0679823
UMLS CUI-2
C1516220
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Similar models

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling boxes or blanks as requested. See separate page for instructions

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
DateCompleted
Item
Date Completed (mm/dd/yyyy)
date
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
Institution
Item
Institution
text
Institution#
Item
Institution #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID # (10. Family History)
text
revised form
Item
If this is a revised or corrected form, indicate by checking box. (1.)
boolean
Item
Who completed this form? (Check one box)
text
CL.1
Code List
Who completed this form? (Check one box)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Staff (Staff)
CL Item
Other Person (Other person)
CL Item
Not Applicable, No Items Completed (Not applicable, no items completed)
Item Group
Patient characteristics
Item
Race (Check one box only)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.2
Code List
Race (Check one box only)
CL Item
White, Not Hispanic Origin (White, not Hispanic origin)
CL Item
Hispanic (Hispanic)
CL Item
Black, Not Hispanic Origin (Black, not Hispanic origin)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
CL Item
Asian (Asian)
CL Item
Native American / Alaskan Nation (Native American / Alaskan Nation)
CL Item
Other, specify (Other, specify)
CL Item
Unknown / I Prefer Not To Answer (Unknown / I prefer not to answer)
Other,specify(race)
Item
Other, specify (race) (2B.)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
text
CL.3
Code List
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
CL Item
White, Not Hispanic Origin (White, not Hispanic origin)
CL Item
Hispanic (Hispanic)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
Black, Not Hispanic Origin (Black, not Hispanic origin)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
CL025744 (NCI Metathesaurus)
CL Item
Asian (Asian)
CL106519 (NCI Metathesaurus)
CL Item
Native American / Alaskan Nation (Native American / Alaskan Nation)
CL Item
Unknown / I Prefer Not To Answer (Unknown / I prefer not to answer)
Item
Highest school grade completed (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property-2)
C1522410 (UMLS 2011AA Property-2)
CL.4
Code List
Highest school grade completed (Check one box)
CL Item
8th Or Less (8th or less)
CL Item
9 - 11th Grade (9 - 11th Grade)
CL Item
High School Graduate / Ged (High school graduate / GED)
CL Item
Vocational / Technical School (Vocational / technical school)
CL Item
Associate Degree / Some College (Associate degree / some college)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other, Specify (Other, specify)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(highestschoolgradecompleted)
Item
Other, specify (highest school grade completed) (4.)
text
Item
Religion during childhood (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property-2)
C0035039 (UMLS 2011AA Property-2)
CL.5
Code List
Religion during childhood (Check one box)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Morman/Latter Day Saints)
CL Item
Muslim / Islam (Muslim / Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(religionduringchildhood)
Item
Other, specify (religion during childhood) (5.)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Marital status (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Marital status (Check one box)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
CL Item
Single (Single)
CL Item
Divorced/separated (Divorced/Separated)
CL Item
Living As Married (Living as married)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Item
Where were you born? (Check one box)
text
CL.7
Code List
Where were you born? (Check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA, specify the 2 letter State code, eg NY)
CL Item
Other Country, Specify (Other country, specify)
USA,specifythe2letterStatecode,egNY
Item
USA, specify the 2 letter State code, eg NY
text
Othercountry,specify(whereyouwereborn)
Item
Other country, specify (where you were born) (7.)
text
Item
Where did you live the longest (Check one box)
text
CL.8
Code List
Where did you live the longest (Check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA, specify the 2 letter State code, eg NY)
CL Item
Other Country, Specify (Other country, specify)
Othercountry,specify(whereyoulivedthelongest)
Item
Other country, specify (where you lived the longest) (8. Cigarette History?)
text
Item
Smoked at least 100 cigarette (5 packs) during lifetime (B.)
text
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
CL.9
Code List
Smoked at least 100 cigarette (5 packs) during lifetime (B.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, But Quit (Yes, but quit)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
Age at starting smoking
Item
Age began smoking cigarettes (C.)
integer
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C18270 (NCI Thesaurus Property-2)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0453999 (UMLS CUI-1)
Smoking years
Item
Number of years smoked cigarettes (D.)
integer
C3260576 (UMLS CUI-1)
number of cigarettes per day
Item
Average number of cigarettes smoked per day (E.)
integer
C25337 (NCI Thesaurus ValueDomain)
C3694146 (UMLS CUI-1)
Smoking cessation age
Item
If quit, age stopped smoking completely
integer
C16960 (NCI Thesaurus ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0085134 (NCI Metathesaurus Property)
C3172720 (UMLS CUI-1)
Item
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
text
C0683519 (UMLS CUI-1)
CL.10
Code List
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
CL Item
Heart Problems (Heart problems)
C0795691 (UMLS CUI-1)
CL Item
Lung Problems (Lung problems)
C0740941 (UMLS CUI-1)
CL Item
High Blood Pressure (High blood pressure)
C0020538 (UMLS CUI-1)
CL Item
Bleeding Problems (Bleeding problems)
C0019080 (UMLS CUI-1)
CL Item
Circulation Problems (Circulation problems)
C0848724 (UMLS CUI-1)
CL Item
Liver Problems (Liver problems)
C0577060 (UMLS CUI-1)
CL Item
Diabetes Or Sugar In Urine (Diabetes or sugar in urine)
C0011849 (UMLS CUI-1)
CL Item
Kidney/urine Problems (Kidney/urine problems)
C0812426 (UMLS CUI-1)
CL Item
Stroke (Stroke)
C0038454 (UMLS CUI-1)
CL Item
Thyroid Problems (Thyroid problems)
C0851024 (UMLS CUI-1)
CL Item
Seizure (Seizure)
C2962 (NCI Thesaurus)
C0036572 (UMLS CUI-1)
CL Item
Hiv/aids (HIV/AIDS)
C0019682 (UMLS CUI-1)
CL Item
Frequent Infections (Frequent infections)
C3829793 (UMLS CUI-1)
CL Item
Psychological Problems (Psychological problems)
C0848067 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
Specifyother(illness)
Item
Specify other (illness)
text
Item Group
Family history
C0241889 (UMLS CUI-1)
Brothers
Item
Brothers
text
C0337527 (UMLS CUI-1)
Sisters
Item
Sisters
text
C0337514 (UMLS CUI-1)
Sons
Item
Sons
text
C0037683 (UMLS CUI-1)
Daughters
Item
Daughters (B.)
text
C0011011 (UMLS CUI-1)
Adopted
Item
Are you adopted? (Check one)
boolean
C16960 (NCI Thesaurus ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS CUI-1)
Item
Blood relative with cancer
text
C25284 (NCI Thesaurus ValueDomain)
C0260515 (UMLS CUI-1)
CL.12
Code List
Blood relative with cancer
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)
CL Item
Brother #1 (Brother #1)
CL Item
Brother #2 (Brother #2)
CL Item
Brother #3 (Brother #3)
CL Item
Brother #4 (Brother #4)
CL Item
Sister #1 (Sister #1)
CL Item
Sister #2 (Sister #2)
CL Item
Sister #3 (Sister #3)
CL Item
Sister #4 (Sister #4)
CL Item
Child #1 (Child #1)
CL Item
Child #2 (Child #2)
CL Item
Child #3 (Child #3)
CL Item
Child #4 (Child #4)
Age at first cancer diagnosis
Item
Age when first cancer diagnosed
integer
C25190 (NCI Thesaurus ObjectClass)
C9305 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C15220 (NCI Thesaurus Property-3)
C25150 (NCI Thesaurus Property-4)
C29848 (NCI Thesaurus ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C3172271 (UMLS CUI-1)
Item
Type of Cancer
text
C0872066 (UMLS CUI-1)
CL.13
Code List
Type of Cancer
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Head & Neck (Head & Neck)
CL Item
Non Melanoma Skin (Non Melanoma Skin)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
specify(othercancers)
Item
specify (other cancers) (11A.)
text
Item Group
Cancer prevention trial
Cancer Prevention Trial
Item
Have you ever heard of Cancer Prevention Trials? (Check one box)
boolean
C38147 (NCI Thesaurus ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C25356 (NCI Thesaurus Property)
C0376554 (NCI Metathesaurus Property)
C1516220 (UMLS CUI-1)
Item
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
integer
C25664 (NCI Thesaurus ValueDomain)
C25608 (NCI Thesaurus Property)
C15790 (NCI Thesaurus ObjectClass)
C0679823 (UMLS CUI-1)
C1516220 (UMLS CUI-2)
CL.15
Code List
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
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