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10560

Description

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE NCT00048997 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

Keywords

  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

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License

Creative Commons BY-NC 3.0 Legacy

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    Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE NCT00048997

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

    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
    Description

    Header Module

    Case #
    Description

    Case#

    Data type

    text

    Institution
    Description

    InstitutionName

    Data type

    text

    Institution No.
    Description

    InstitutionNo.

    Data type

    text

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

    Patient'sName

    Data type

    text

    Patient's I.D. No.
    Description

    Patient'sI.D.No.

    Data type

    text

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

    Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

    Data type

    text

    Neurocognitive Evaluation
    Description

    Neurocognitive Evaluation

    Calender Due Date
    Description

    CalenderDueDate

    Data type

    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
    Description

    Dateofexamination

    Data type

    text

    Date of 1st protocol Rx
    Description

    FirstTreatmentStartDate

    Data type

    date

    What is the year
    Description

    Whatistheyear

    Data type

    text

    What is the season
    Description

    Whatistheseason

    Data type

    text

    What is the date
    Description

    Whatisthedate

    Data type

    text

    What is the day
    Description

    Whatistheday

    Data type

    text

    What is the month
    Description

    Whatisthemonth

    Data type

    text

    What is the, Score
    Description

    Whatisthe,Score

    Data type

    text

    Where are we, state
    Description

    Wherearewe,state

    Data type

    text

    Where are we, country
    Description

    Wherearewe,country

    Data type

    text

    Where are we, town
    Description

    Wherearewe,town

    Data type

    text

    Where are we, hospital
    Description

    Wherearewe,hospital

    Data type

    text

    Where are we, floor
    Description

    Wherearewe,floor

    Data type

    text

    Where are we, Score
    Description

    Wherearewe,Score

    Data type

    text

    Registration Score
    Description

    RegistrationScore

    Data type

    text

    Attention and Calculation Score
    Description

    AttentionandCalculationScore

    Data type

    text

    Recall Score (Language)
    Description

    RecallScore

    Data type

    text

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

    Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

    Data type

    text

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

    Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

    Data type

    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."
    Description

    Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

    Data type

    text

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

    Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

    Data type

    text

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

    Havethepatientwriteasentencewithasubjectandaverb

    Data type

    text

    Have the patient copy the figure
    Description

    Havethepatientcopythefigure

    Data type

    text

    MMSE Total Score
    Description

    MMSETotalScore

    Data type

    text

    Assess level of consciousness along a continuum
    Description

    Assesslevelofconsciousnessalongacontinuum

    Data type

    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.
    Description

    Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

    Data type

    text

    Name/signature of person performing exam
    Description

    Name/signatureofpersonperformingexam

    Data type

    text

    Date
    Description

    Date

    Data type

    date

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

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

    Similar models

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

    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
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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
    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
    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
    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
    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
    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
    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
    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
    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
    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
    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
    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
    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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