ID

10560

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

3 juni 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE NCT00048997

Engels

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

1 Formulieren  
  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
Beschrijving

Header Module

Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

InstitutionName

Datatype

text

Institution No.
Beschrijving

InstitutionNo.

Datatype

text

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

Patient'sName

Datatype

text

Patient's I.D. No.
Beschrijving

Patient'sI.D.No.

Datatype

text

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

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Datatype

text

Neurocognitive Evaluation
Beschrijving

Neurocognitive Evaluation

Calender Due Date
Beschrijving

CalenderDueDate

Datatype

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
Beschrijving

Dateofexamination

Datatype

text

Date of 1st protocol Rx
Beschrijving

FirstTreatmentStartDate

Datatype

date

What is the year
Beschrijving

Whatistheyear

Datatype

text

What is the season
Beschrijving

Whatistheseason

Datatype

text

What is the date
Beschrijving

Whatisthedate

Datatype

text

What is the day
Beschrijving

Whatistheday

Datatype

text

What is the month
Beschrijving

Whatisthemonth

Datatype

text

What is the, Score
Beschrijving

Whatisthe,Score

Datatype

text

Where are we, state
Beschrijving

Wherearewe,state

Datatype

text

Where are we, country
Beschrijving

Wherearewe,country

Datatype

text

Where are we, town
Beschrijving

Wherearewe,town

Datatype

text

Where are we, hospital
Beschrijving

Wherearewe,hospital

Datatype

text

Where are we, floor
Beschrijving

Wherearewe,floor

Datatype

text

Where are we, Score
Beschrijving

Wherearewe,Score

Datatype

text

Registration Score
Beschrijving

RegistrationScore

Datatype

text

Attention and Calculation Score
Beschrijving

AttentionandCalculationScore

Datatype

text

Recall Score (Language)
Beschrijving

RecallScore

Datatype

text

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

Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

Datatype

text

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

Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

Datatype

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."
Beschrijving

Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

Datatype

text

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

Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

Datatype

text

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

Havethepatientwriteasentencewithasubjectandaverb

Datatype

text

Have the patient copy the figure
Beschrijving

Havethepatientcopythefigure

Datatype

text

MMSE Total Score
Beschrijving

MMSETotalScore

Datatype

text

Assess level of consciousness along a continuum
Beschrijving

Assesslevelofconsciousnessalongacontinuum

Datatype

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.
Beschrijving

Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

Datatype

text

Name/signature of person performing exam
Beschrijving

Name/signatureofpersonperformingexam

Datatype

text

Date
Beschrijving

Date

Datatype

date

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

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 Formulieren
  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)
Datatype
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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