ID

10457

Descripción

Radiation Therapy Oncology Group Demographic Data Form - Version 2 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=9EC372A6-6D13-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-6D13-05D5-E034-080020C9C0E0

Palabras clave

  1. 19/9/12 19/9/12 -
  2. 11/8/14 11/8/14 - Martin Dugas
  3. 2/6/15 2/6/15 -
  4. 3/6/15 3/6/15 -
Subido en

2 de junio de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy

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Radiation Therapy Oncology Group Demographic Data Form - Version 2

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Demographic Data Form - Version 2
    1. No Instruction available.
Header module
Descripción

Header module

Date Completed
Descripción

FormCompletionDate,Original

Tipo de datos

date

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

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient administration
Descripción

Patient administration

Case #
Descripción

Case#

Tipo de datos

text

Institution
Descripción

InstitutionName

Tipo de datos

text

Institution #
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name
Descripción

PatientName

Tipo de datos

text

Patient ID #
Descripción

PatientID#

Tipo de datos

text

Patient demographics
Descripción

Patient demographics

Who completed this form? (Check one box)
Descripción

Whocompletedthisform?

Tipo de datos

text

Race (Check one box only)
Descripción

PatientRace/Ethnicity

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Race Other, specify
Descripción

RaceOther,specify

Tipo de datos

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.)
Descripción

AdditionalRace/Ethnicity

Tipo de datos

text

Highest school grade completed (Check one box)
Descripción

Highestschoolgradecompleted

Tipo de datos

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
Highest school grade completed Other, specify
Descripción

HighestschoolgradecompletedOther,specify

Tipo de datos

text

Religion during childhood (Check one box)
Descripción

PersonPediatricReligionName

Tipo de datos

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
Religion during childhood Other, specify
Descripción

ReligionduringchildhoodOther,specify

Tipo de datos

text

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

Maritalstatus

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Where were you born? (Check the box of the country where you were born.)
Descripción

Wherewereyouborn?

Tipo de datos

text

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

USA,specifythe2letterStatecode,egNY

Tipo de datos

text

Where were you born, other country, specify
Descripción

PatientAddress,Country

Tipo de datos

text

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

Wheredidyoulivethelongest

Tipo de datos

text

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

USA,specifythe2letterStatecode,egNY

Tipo de datos

text

Where did you live the longest, other country, specify
Descripción

Wheredidyoulivethelongest,othercountry,specify

Tipo de datos

text

Smoked at least 100 cigarette (5 packs) during lifetime
Descripción

Smoking history

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1519384
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C29719
Age began smoking cigarettes
Descripción

PatientInitialCigaretteSmokingAgeYearCount

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property-2
C18270
UMLS 2011AA Property-2
C0700219
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Number of years smoked cigarettes
Descripción

Numberofyearssmokedcigarettes

Tipo de datos

text

Average number of cigarettes smoked per day
Descripción

Averagenumberofcigarettessmokedperday

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If quit, age stopped smoking completely
Descripción

PatientSmokingCessationAgeYear

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Metathesaurus Property
C0085134
If you have had any of the illness listed below, please check yes for those that apply.
Descripción

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Tipo de datos

text

Illness, specify other
Descripción

Illness,specifyother

Tipo de datos

text

How many of the following family members (living and dead) do you have? (Include only those who are blood-related.)
Descripción

Howmanyofthefollowingfamilymembers(livinganddead)doyouhave?

Tipo de datos

text

Brothers
Descripción

Brothers

Tipo de datos

text

Sisters
Descripción

Sisters

Tipo de datos

text

Sons
Descripción

Sons

Tipo de datos

text

Daughters
Descripción

Daughters

Tipo de datos

text

Are you adopted? (Check one)
Descripción

Areyouadopted?

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25290
UMLS 2011AA Property
C0425382
Blood relative with cancer
Descripción

Bloodrelativewithcancer

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Age when first cancer diagnosed
Descripción

PersonFirstCancerDiagnosisAgeYearCount

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property-2
C25509
UMLS 2011AA Property-2
C1279901
NCI Thesaurus Property-3
C15220
UMLS 2011AA Property-3
C0011900
NCI Thesaurus Property-4
C25150
UMLS 2011AA Property-4
C0001779
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Type of Cancer
Descripción

TypeofCancer

Tipo de datos

text

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

CancerPreventionTrialKnowledgeDocumentedInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Metathesaurus Property
C0376554
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.)
Descripción

CancerPreventionTrialParticipationScale

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220

Similar models

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Demographic Data Form - Version 2
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header module
FormCompletionDate,Original
Item
Date Completed
date
AmendedDataInd
Item
If this is a revised or corrected form, indicate by checking box.
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Patient administration
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
NCIInstitutionNumber
Item
Institution #
text
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID #
text
Item Group
Patient demographics
Item
Who completed this form? (Check one box)
text
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
Race (Check one box only)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
Code List
Race (Check one box only)
CL Item
White, not Hispanic origin (White, not 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, not Hispanic origin (Black, not Hispanic origin)
CL Item
Pacific_islander_cdus (Native Hawaiian or other Pacific Islander)
CL Item
Asian_cdus (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)
RaceOther,specify
Item
Race Other, specify
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
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)
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)
HighestschoolgradecompletedOther,specify
Item
Highest school grade completed Other, specify
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)
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)
ReligionduringchildhoodOther,specify
Item
Religion during childhood Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Marital status (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
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 the box of the country where you were born.)
text
Code List
Where were you born? (Check the box of the country where you were born.)
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
PatientAddress,Country
Item
Where were you born, other country, specify
text
Item
Where did you live the longest (Check one box)
text
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)
USA,specifythe2letterStatecode,egNY
Item
USA, specify the 2 letter State code, eg NY
text
Wheredidyoulivethelongest,othercountry,specify
Item
Where did you live the longest, other country, specify
text
Item
Smoked at least 100 cigarette (5 packs) during lifetime
text
C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)
Code List
Smoked at least 100 cigarette (5 packs) during lifetime
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)
PatientInitialCigaretteSmokingAgeYearCount
Item
Age began smoking cigarettes
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property-2)
C0700219 (UMLS 2011AA Property-2)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Numberofyearssmokedcigarettes
Item
Number of years smoked cigarettes
text
Averagenumberofcigarettessmokedperday
Item
Average number of cigarettes smoked per day
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientSmokingCessationAgeYear
Item
If quit, age stopped smoking completely
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C0085134 (NCI Metathesaurus Property)
Item
If you have had any of the illness listed below, please check yes for those that apply.
text
Code List
If you have had any of the illness listed below, please check yes for those that apply.
CL Item
Heart Problems (Heart problems)
CL Item
Lung Problems (Lung problems)
CL Item
High Blood Pressure (High blood pressure)
CL Item
Bleeding Problems (Bleeding problems)
CL Item
Circulation Problems (Circulation problems)
CL Item
Liver Problems (Liver problems)
CL Item
Diabetes Or Sugar In Urine (Diabetes or sugar in urine)
CL Item
Kidney/urine Problems (Kidney/urine problems)
CL Item
Stroke (Stroke)
CL Item
Thyroid Problems (Thyroid problems)
CL Item
Seizure (Seizure)
C2962 (NCI Thesaurus)
C0036572 (UMLS 2011AA)
CL Item
Hiv/aids (HIV/AIDS)
CL Item
Frequent Infections (Frequent infections)
CL Item
Psychological Problems (Psychological problems)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Illness, Specify Other (Illness, specify other)
Illness,specifyother
Item
Illness, specify other
text
Item
How many of the following family members (living and dead) do you have? (Include only those who are blood-related.)
text
Code List
How many of the following family members (living and dead) do you have? (Include only those who are blood-related.)
CL Item
Brothers (Brothers)
CL Item
Sisters (Sisters)
C0337514 (NCI Metathesaurus)
CL Item
Sons (Sons)
CL Item
Daughters (Daughters)
Brothers
Item
Brothers
text
Sisters
Item
Sisters
text
Sons
Item
Sons
text
Daughters
Item
Daughters
text
Areyouadopted?
Item
Are you adopted? (Check one)
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
Item
Blood relative with cancer
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
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)
PersonFirstCancerDiagnosisAgeYearCount
Item
Age when first cancer diagnosed
float
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property-2)
C1279901 (UMLS 2011AA Property-2)
C15220 (NCI Thesaurus Property-3)
C0011900 (UMLS 2011AA Property-3)
C25150 (NCI Thesaurus Property-4)
C0001779 (UMLS 2011AA Property-4)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Type of Cancer
text
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)
CancerPreventionTrialKnowledgeDocumentedInd-2
Item
Have you ever heard of Cancer Prevention Trials? (Check one box)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
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.)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
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)
C0205448 (UMLS 2011AA)
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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