ID

10560

Beskrivning

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

Länk

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

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-05-28 2015-05-28 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

3 juni 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

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

Engelsk

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

1 Formulär  
  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
Beskrivning

Header Module

Case #
Beskrivning

Case#

Datatyp

text

Institution
Beskrivning

InstitutionName

Datatyp

text

Institution No.
Beskrivning

InstitutionNo.

Datatyp

text

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

Patient'sName

Datatyp

text

Patient's I.D. No.
Beskrivning

Patient'sI.D.No.

Datatyp

text

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

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Datatyp

text

Neurocognitive Evaluation
Beskrivning

Neurocognitive Evaluation

Calender Due Date
Beskrivning

CalenderDueDate

Datatyp

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
Beskrivning

Dateofexamination

Datatyp

text

Date of 1st protocol Rx
Beskrivning

FirstTreatmentStartDate

Datatyp

date

What is the year
Beskrivning

Whatistheyear

Datatyp

text

What is the season
Beskrivning

Whatistheseason

Datatyp

text

What is the date
Beskrivning

Whatisthedate

Datatyp

text

What is the day
Beskrivning

Whatistheday

Datatyp

text

What is the month
Beskrivning

Whatisthemonth

Datatyp

text

What is the, Score
Beskrivning

Whatisthe,Score

Datatyp

text

Where are we, state
Beskrivning

Wherearewe,state

Datatyp

text

Where are we, country
Beskrivning

Wherearewe,country

Datatyp

text

Where are we, town
Beskrivning

Wherearewe,town

Datatyp

text

Where are we, hospital
Beskrivning

Wherearewe,hospital

Datatyp

text

Where are we, floor
Beskrivning

Wherearewe,floor

Datatyp

text

Where are we, Score
Beskrivning

Wherearewe,Score

Datatyp

text

Registration Score
Beskrivning

RegistrationScore

Datatyp

text

Attention and Calculation Score
Beskrivning

AttentionandCalculationScore

Datatyp

text

Recall Score (Language)
Beskrivning

RecallScore

Datatyp

text

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

Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

Datatyp

text

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

Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

Datatyp

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."
Beskrivning

Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

Datatyp

text

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

Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

Datatyp

text

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

Havethepatientwriteasentencewithasubjectandaverb

Datatyp

text

Have the patient copy the figure
Beskrivning

Havethepatientcopythefigure

Datatyp

text

MMSE Total Score
Beskrivning

MMSETotalScore

Datatyp

text

Assess level of consciousness along a continuum
Beskrivning

Assesslevelofconsciousnessalongacontinuum

Datatyp

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.
Beskrivning

Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

Datatyp

text

Name/signature of person performing exam
Beskrivning

Name/signatureofpersonperformingexam

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

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

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

Tillbaka till toppen

Similar models

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

1 Formulär
  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
Typ
Description | Question | Decode (Coded Value)
Datatyp
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
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial