ID

10362

Descrição

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A5D1AB4A-E01B-3595-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A5D1AB4A-E01B-3595-E034-080020C9C0E0

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
Transferido a

28 de maio de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE

Inglês

Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.

1 Formulários  
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE
    1. Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.
Header Module
Descrição

Header Module

Case #
Descrição

Case#

Tipo de dados

text

Institution
Descrição

InstitutionName

Tipo de dados

text

Institution No.
Descrição

InstitutionNo.

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient's Name
Descrição

Patient'sName

Tipo de dados

text

Patient's I.D. No.
Descrição

Patient'sI.D.No.

Tipo de dados

text

If this is a revised or corrected form, indicate by checking box.
Descrição

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Tipo de dados

text

Neurocognitive Evaluation
Descrição

Neurocognitive Evaluation

Calender Due Date
Descrição

CalenderDueDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C19459
UMLS 2011AA ObjectClass
C1516147
NCI Thesaurus Property
C45263
UMLS 2011AA Property
C0678226
Date of examination
Descrição

Dateofexamination

Tipo de dados

text

Date of 1st protocol Rx
Descrição

FirstTreatmentStartDate

Tipo de dados

date

What is the year
Descrição

Whatistheyear

Tipo de dados

text

What is the season
Descrição

Whatistheseason

Tipo de dados

text

What is the date
Descrição

Whatisthedate

Tipo de dados

text

What is the day
Descrição

Whatistheday

Tipo de dados

text

What is the month
Descrição

Whatisthemonth

Tipo de dados

text

What is the, Score
Descrição

Whatisthe,Score

Tipo de dados

text

Where are we, state
Descrição

Wherearewe,state

Tipo de dados

text

Where are we, country
Descrição

Wherearewe,country

Tipo de dados

text

Where are we, town
Descrição

Wherearewe,town

Tipo de dados

text

Where are we, hospital
Descrição

Wherearewe,hospital

Tipo de dados

text

Where are we, floor
Descrição

Wherearewe,floor

Tipo de dados

text

Where are we, Score
Descrição

Wherearewe,Score

Tipo de dados

text

Registration Score
Descrição

RegistrationScore

Tipo de dados

text

Attention and Calculation Score
Descrição

AttentionandCalculationScore

Tipo de dados

text

Recall Score (Language)
Descrição

RecallScore

Tipo de dados

text

Point to the following objects and have patient name each: a pencil and a watch
Descrição

Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

Tipo de dados

text

Have the patient repeat the following: "No ifs, ands or buts"
Descrição

Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

Tipo de dados

text

Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
Descrição

Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

Tipo de dados

text

Show the patient the statement "Close your eyes and him read and obey what it says.
Descrição

Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

Tipo de dados

text

Have the patient write a sentence with a subject and a verb
Descrição

Havethepatientwriteasentencewithasubjectandaverb

Tipo de dados

text

Have the patient copy the figure
Descrição

Havethepatientcopythefigure

Tipo de dados

text

MMSE Total Score
Descrição

MMSETotalScore

Tipo de dados

text

Assess level of consciousness along a continuum
Descrição

Assesslevelofconsciousnessalongacontinuum

Tipo de dados

text

If an evaluation is not done, provide the time point missed and the reason. If none of the tests are done, provide the reason.
Descrição

Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

Tipo de dados

text

Name/signature of person performing exam
Descrição

Name/signatureofpersonperformingexam

Tipo de dados

text

Date
Descrição

Date

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse
Descrição

Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse

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Similar models

Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.

1 Formulários
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE
    1. Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Header Module
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
Patient'sI.D.No.
Item
Patient's I.D. No.
text
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box.
text
Item Group
Neurocognitive Evaluation
CalenderDueDate
Item
Calender Due Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19459 (NCI Thesaurus ObjectClass)
C1516147 (UMLS 2011AA ObjectClass)
C45263 (NCI Thesaurus Property)
C0678226 (UMLS 2011AA Property)
Dateofexamination
Item
Date of examination
text
FirstTreatmentStartDate
Item
Date of 1st protocol Rx
date
Whatistheyear
Item
What is the year
text
Whatistheseason
Item
What is the season
text
Whatisthedate
Item
What is the date
text
Whatistheday
Item
What is the day
text
Whatisthemonth
Item
What is the month
text
Item
What is the, Score
text
CL.1
Code List
What is the, Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Wherearewe,state
Item
Where are we, state
text
Wherearewe,country
Item
Where are we, country
text
Wherearewe,town
Item
Where are we, town
text
Wherearewe,hospital
Item
Where are we, hospital
text
Wherearewe,floor
Item
Where are we, floor
text
Item
Where are we, Score
text
CL.2
Code List
Where are we, Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Registration Score
text
CL.3
Code List
Registration Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Attention and Calculation Score
text
CL.4
Code List
Attention and Calculation Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Recall Score (Language)
text
CL.5
Code List
Recall Score (Language)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Point to the following objects and have patient name each: a pencil and a watch
text
CL.6
Code List
Point to the following objects and have patient name each: a pencil and a watch
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
Item
Have the patient repeat the following: "No ifs, ands or buts"
text
CL.7
Code List
Have the patient repeat the following: "No ifs, ands or buts"
CL Item
1 (1)
Item
Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
text
CL.8
Code List
Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Show the patient the statement "Close your eyes and him read and obey what it says.
text
CL.9
Code List
Show the patient the statement "Close your eyes and him read and obey what it says.
CL Item
1 (1)
Item
Have the patient write a sentence with a subject and a verb
text
CL.10
Code List
Have the patient write a sentence with a subject and a verb
CL Item
1 (1)
Item
Have the patient copy the figure
text
CL.11
Code List
Have the patient copy the figure
CL Item
1 (1)
MMSETotalScore
Item
MMSE Total Score
text
Item
Assess level of consciousness along a continuum
text
CL.12
Code List
Assess level of consciousness along a continuum
CL Item
Alert (alert)
C64358 (NCI Thesaurus)
C0718338 (UMLS 2011AA)
CL Item
Drowsy (drowsy)
CL Item
Stupor (stupor)
CL Item
Coma (coma)
C34497 (NCI Thesaurus)
C0009421 (UMLS 2011AA)
Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.
Item
If an evaluation is not done, provide the time point missed and the reason. If none of the tests are done, provide the reason.
text
Name/signatureofpersonperformingexam
Item
Name/signature of person performing exam
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse
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