ID

10526

Descripción

Assessment Compliance Form NCT00058149 A Phase III, Randomized Study of Gemcitabine (Fixed-Dose Rate Infusion) and Oxaliplatin (NSC 266046) Versus Gemcitabine (Fixed-Dose Rate Infusion) Versus Gemcitabine (30-Minute Infusion) in Pancreatic Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6276EB5-A819-3D71-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6276EB5-A819-3D71-E034-0003BA0B1A09

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 1/6/15 1/6/15 -
  3. 3/6/15 3/6/15 -
Subido en

3 de junio de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Assessment Compliance Form NCT00058149

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: Assessment Compliance Form
    1. No Instruction available.
ECOG clinical trial administrative data
Descripción

ECOG clinical trial administrative data

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient?s Name
Descripción

Patient'sName

Tipo de datos

text

ECOG Protocol No.
Descripción

ECOGProtocolNo.

Tipo de datos

text

ECOG Protocol No.
Descripción

ECOGProtocolNo.

Tipo de datos

text

ECOG Patient ID
Descripción

ECOGPatientID

Tipo de datos

text

ECOG Patient ID
Descripción

ECOGPatientID

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Participating Group Patient ID
Descripción

ParticipatingGroupPatientID

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

data amendment
Descripción

data amendment

Are data amended? (If yes, please circle amended items in red)
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Assessment Form No.
Descripción

AssessmentFormNo.

Tipo de datos

text

Date Assessment Scheduled (M D Y)
Descripción

DateAssessmentScheduled

Tipo de datos

text

Was Assessment Form completed? (Choose one:)
Descripción

AssessmentFormCompletedInd-2

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C25367
Time point (Choose one:)
Descripción

Timepoint

Tipo de datos

text

other, specify
Descripción

Timepoint,otherspecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
If Assessment Was Completed
Descripción

If Assessment Was Completed

Date Assessment Form completed (M D Y)
Descripción

DateAssessmentFormcompleted

Tipo de datos

text

If Assessment Is Intended To Be Self-administered
Descripción

If Assessment Is Intended To Be Self-administered

Was Assessment self-administered? (Choose one:)
Descripción

WasAssessmentself-administered?

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25217
UMLS 2011AA ObjectClass
C1516048
NCI Thesaurus Property
C25670
UMLS 2011AA Property
C1519231
If NO, how was patient assisted? (Choose one:)
Descripción

IfNO,howwaspatientassisted?

Tipo de datos

text

If NO, what was the reason? (Choose one:)
Descripción

IfNO,whatwasthereason?

Tipo de datos

text

specify language
Descripción

Languagedifficulty,specifylanguage

Tipo de datos

text

please specify
Descripción

disability,pleasespecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
other, please specify
Descripción

other,pleasespecify(reason)

Tipo de datos

text

If NO, who assisted or completed assessment? (Choose one:)
Descripción

IfNO,whoassistedorcompletedassessment?

Tipo de datos

text

other, please specify
Descripción

other,pleasespecify(whoassistedorcompletedassessment)

Tipo de datos

text

If Assessment Was Not Completed
Descripción

If Assessment Was Not Completed

Indicate primary reason why form was not completed (Choose one:)
Descripción

Indicateprimaryreasonwhyformwasnotcompleted

Tipo de datos

text

unable to accommodate disability or language needs please specify
Descripción

unabletoaccommodatedisabilityorlanguageneedspleasespecify

Tipo de datos

text

patient did not show up in clinic/office please specify
Descripción

patientdidnotshowupinclinic/officepleasespecify

Tipo de datos

text

assessment not required per protocol please specify
Descripción

assessmentnotrequiredperprotocolpleasespecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
other, please specify
Descripción

other,pleasespecify(reason)

Tipo de datos

text

Comment
Descripción

Comment

Comments
Descripción

Comments

Tipo de datos

text

Investigator Signature
Descripción

InvestigatorSignature

Tipo de datos

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Descripción

InvestigatorSignatureDate

Tipo de datos

date

Ccrr Module For Assessment Compliance Form
Descripción

Ccrr Module For Assessment Compliance Form

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: Assessment Compliance Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
ECOG clinical trial administrative data
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
data amendment
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AssessmentFormNo.
Item
Assessment Form No.
text
DateAssessmentScheduled
Item
Date Assessment Scheduled (M D Y)
text
Item
Was Assessment Form completed? (Choose one:)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ObjectClass)
CL.2
Code List
Was Assessment Form completed? (Choose one:)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Time point (Choose one:)
text
CL.3
Code List
Time point (Choose one:)
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
8 weeks (8 weeks)
CL Item
16 weeks (16 weeks)
CL Item
Other, Specify (other, specify)
Timepoint,otherspecify
Item
other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
If Assessment Was Completed
DateAssessmentFormcompleted
Item
Date Assessment Form completed (M D Y)
text
Item Group
If Assessment Is Intended To Be Self-administered
Item
Was Assessment self-administered? (Choose one:)
text
C25217 (NCI Thesaurus ObjectClass)
C1516048 (UMLS 2011AA ObjectClass)
C25670 (NCI Thesaurus Property)
C1519231 (UMLS 2011AA Property)
CL.4
Code List
Was Assessment self-administered? (Choose one:)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
If NO, how was patient assisted? (Choose one:)
text
CL.5
Code List
If NO, how was patient assisted? (Choose one:)
CL Item
Questions Were Read Aloud To Patient (questions were read aloud to patient)
CL Item
Patient Required Clarification Of Questions Or Instructions (patient required clarification of questions or instructions)
CL Item
Patient Required Other Assistance (patient required other assistance)
CL Item
Completed Independently By Another Person (completed independently by another person)
Item
If NO, what was the reason? (Choose one:)
text
CL.6
Code List
If NO, what was the reason? (Choose one:)
CL Item
Language Difficulty (questions Needed To Be Translated), Specify Language (language difficulty (questions needed to be translated), specify language)
CL Item
Literacy Difficulty (patient Could Not Read Well Enough) (literacy difficulty (patient could not read well enough))
CL Item
Disability, Please Specify (disability, please specify)
CL Item
Telephone Interview (telephone interview)
CL Item
Other, Please Specify (other, please specify)
Languagedifficulty,specifylanguage
Item
specify language
text
disability,pleasespecify
Item
please specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
other,pleasespecify(reason)
Item
other, please specify
text
Item
If NO, who assisted or completed assessment? (Choose one:)
text
CL.7
Code List
If NO, who assisted or completed assessment? (Choose one:)
CL Item
Staff (staff)
CL Item
Family (family)
C25173 (NCI Thesaurus)
C0015576 (UMLS 2011AA)
CL Item
Friend (friend)
CL Item
Other, Please Specify (other, please specify)
other,pleasespecify(whoassistedorcompletedassessment)
Item
other, please specify
text
Item Group
If Assessment Was Not Completed
Item
Indicate primary reason why form was not completed (Choose one:)
text
CL.8
Code List
Indicate primary reason why form was not completed (Choose one:)
CL Item
Patient Refusal (patient refusal)
CL Item
Unable To Accommodate Disability Or Language Needs Please Specify (unable to accommodate disability or language needs please specify)
CL Item
Patient Did Not Show Up In Clinic/office Please Specify (patient did not show up in clinic/office please specify)
CL Item
Staff Unavailable (staff unavailable)
CL Item
Patient Not Given Form By Staff (patient not given form by staff)
CL Item
Patient Too Ill (patient too ill)
CL Item
Patient Expired (patient expired)
CL Item
Assessment Not Required Per Protocol Please Specify (assessment not required per protocol please specify)
CL Item
Staff Thought Patient Too Ill (staff thought patient too ill)
CL Item
Other, Please Specify (other, please specify)
unabletoaccommodatedisabilityorlanguageneedspleasespecify
Item
unable to accommodate disability or language needs please specify
text
patientdidnotshowupinclinic/officepleasespecify
Item
patient did not show up in clinic/office please specify
text
assessmentnotrequiredperprotocolpleasespecify
Item
assessment not required per protocol please specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
other,pleasespecify(reason)
Item
other, please specify
text
Item Group
Comment
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Assessment Compliance Form
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