ID

10564

Description

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form 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=A5472EED-0175-07F2-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A5472EED-0175-07F2-E034-080020C9C0E0

Keywords

Versions (3)
  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

DOI

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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 Neurocognitive Evaluation Summary Form NCT00048997

English

No Instruction available.

1 forms  
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form
    1. No Instruction available.
Header Module
Description

Header Module

Case #
Description

Case#

Data type

text

Institution
Description

Institution

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. (Time Point of Assessment)
Description

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Data type

text

Neurocognitive Evaluation
Description

Neurocognitive Evaluation

Baseline/Prert
Description

Baseline/Prert

Data type

text

Month During Follow-up (HVLT Administration)
Description

MonthDuringFollow-up

Data type

text

Code reason test not done
Description

Codereasontestnotdone

Data type

text

Other reason test omitted specify (HVLT Results)
Description

Otherreasontestomittedspecify

Data type

text

Trial #1, #2, #3 Recall, Total Score
Description

Trial#1,#2,#3Recall,TotalScore

Data type

text

Trial #4 Recognition, Total Score
Description

Trial#4Recognition,TotalScore

Data type

text

Time test completed
Description

Timetestcompleted

Data type

text

Trial #5 Delayed Recall, Start Time
Description

Trial#5DelayedRecall,StartTime

Data type

text

Trial #5 Delayed Recall, Total Score
Description

Trial#5DelayedRecall,TotalScore

Data type

text

Comments
Description

Comments

Data type

text

Signature
Description

Signature

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 Neurocognitive Evaluation Summary Form
Description

Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Neurocognitive Evaluation Summary Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Case#
Item
Case #
text
Institution
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. (Time Point of Assessment)
text
Item Group
Neurocognitive Evaluation
Baseline/Prert
Item
Baseline/Prert
text
Item
Month During Follow-up (HVLT Administration)
text
CL.1
Code List
Month During Follow-up (HVLT Administration)
CL Item
1 (1)
CL Item
3 (3)
CL Item
6 (6)
CL Item
12 (12)
CL Item
18 (18)
CL Item
24 (24)
CL Item
30 (30)
CL Item
36 (36)
CL Item
48 (48)
Item
Code reason test not done
text
CL.2
Code List
Code reason test not done
CL Item
Test Omitted, Patient Unable To Comprehend Instructions (Test omitted, patient unable to comprehend instructions)
CL Item
Test Omitted, Patient Refused (Test omitted, patient refused)
CL Item
Test Omitted Due To Institution/investigator Error (Test omitted due to institution/investigator error)
CL Item
Other Reason Test Omitted Specify (Other reason test omitted specify)
CL Item
Reason Unknown (Reason unknown)
Otherreasontestomittedspecify
Item
Other reason test omitted specify (HVLT Results)
text
Trial#1,#2,#3Recall,TotalScore
Item
Trial #1, #2, #3 Recall, Total Score
text
Trial#4Recognition,TotalScore
Item
Trial #4 Recognition, Total Score
text
Timetestcompleted
Item
Time test completed
text
Trial#5DelayedRecall,StartTime
Item
Trial #5 Delayed Recall, Start Time
text
Trial#5DelayedRecall,TotalScore
Item
Trial #5 Delayed Recall, Total Score
text
Comments
Item
Comments
text
Signature
Item
Signature
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 Neurocognitive Evaluation Summary Form
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