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ID
10564
Beschrijving
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
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- 19-09-12 19-09-12 -
- 28-05-15 28-05-15 -
- 03-06-15 03-06-15 -
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3 juni 2015
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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
No Instruction available.
- StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form
Similar models
No Instruction available.
- StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Neurocognitive Evaluation Summary Form
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Case#
Item
Case #
text
Institution
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA 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
Baseline/Prert
Item
Baseline/Prert
text
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)
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)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Neurocognitive Evaluation Summary Form