ID

10564

Descripción

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

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
Subido en

3 de junio de 2015

DOI

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Licencia

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

Inglés

No Instruction available.

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

Header Module

Case #
Descripción

Case#

Tipo de datos

text

Institution
Descripción

Institution

Tipo de datos

text

Institution No.
Descripción

InstitutionNo.

Tipo de datos

text

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

Patient'sName

Tipo de datos

text

Patient's I.D. No.
Descripción

Patient'sI.D.No.

Tipo de datos

text

If this is a revised or corrected form, indicate by checking box. (Time Point of Assessment)
Descripción

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Tipo de datos

text

Neurocognitive Evaluation
Descripción

Neurocognitive Evaluation

Baseline/Prert
Descripción

Baseline/Prert

Tipo de datos

text

Month During Follow-up (HVLT Administration)
Descripción

MonthDuringFollow-up

Tipo de datos

text

Code reason test not done
Descripción

Codereasontestnotdone

Tipo de datos

text

Other reason test omitted specify (HVLT Results)
Descripción

Otherreasontestomittedspecify

Tipo de datos

text

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

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

Tipo de datos

text

Trial #4 Recognition, Total Score
Descripción

Trial#4Recognition,TotalScore

Tipo de datos

text

Time test completed
Descripción

Timetestcompleted

Tipo de datos

text

Trial #5 Delayed Recall, Start Time
Descripción

Trial#5DelayedRecall,StartTime

Tipo de datos

text

Trial #5 Delayed Recall, Total Score
Descripción

Trial#5DelayedRecall,TotalScore

Tipo de datos

text

Comments
Descripción

Comments

Tipo de datos

text

Signature
Descripción

Signature

Tipo de datos

text

Date
Descripción

Date

Tipo de datos

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
Descripción

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 formularios
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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