0 Evaluaciones

ID

10769

Descripción

E4A08 Assessment Compliance Form NCT01078454 Melphalan and Dexamethasone With or Without Bortezomib in Treating Patients With Previously Untreated Systemic Light-Chain Amyloidosis Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9FB6753F-27C0-044C-E040-BB89AD436EED

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9FB6753F-27C0-044C-E040-BB89AD436EED

Palabras clave

  1. 19/9/12 19/9/12 -
  2. 8/1/15 8/1/15 - Martin Dugas
  3. 8/6/15 8/6/15 -
Subido en

8 de junio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy

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    E4A08 Assessment Compliance Form NCT01078454

    INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

    ECOG clinical trial administrative data
    Descripción

    ECOG clinical trial administrative data

    ECOG Protocol Number
    Descripción

    Protocol Number ECOG

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    DCI Name
    Descripción

    Generic drug form

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C3242750
    NCI Thesaurus Property
    C19464
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus ObjectClass-2
    C25452
    Registration Step
    Descripción

    Registration Number

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    ECOG Patient ID
    Descripción

    Patient ID ECOG

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    Patient demographics
    Descripción

    Patient demographics

    Patient Initials (Last, First)
    Descripción

    Patient Initials

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    ECOG Protocol Number
    Descripción

    Protocol Number ECOG

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    Participating Group Protocol Number
    Descripción

    Study Number Participating Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Institution/Affiliate
    Descripción

    Institution Name

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    ECOG Patient ID
    Descripción

    Patient ID ECOG

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    Participating Group Patient ID
    Descripción

    Trial subject ID Participating Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Reporting period
    Descripción

    Reporting period

    On Treatment Report Period
    Descripción

    Cycle number

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25214
    NCI Thesaurus Property-2
    C25616
    NCI Thesaurus ObjectClass
    C15368
    Off Treatment Report Period
    Descripción

    PersonOff-TreatmentTimePeriodType

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property-2
    C25601
    UMLS 2011AA Property-2
    C1518544
    NCI Thesaurus Property-3
    C25207
    UMLS 2011AA Property-3
    C0040223
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Date of Assessment (If not completed, enter date scheduled per E4A08 protocol.)
    Descripción

    Assessment Date

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2985720
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C38000
    Section Ii - E1a05 Qol Assessment Not Completed
    Descripción

    Section Ii - E1a05 Qol Assessment Not Completed

    Were both of the Assessment Forms completed? (E4A08 Quality of Life)
    Descripción

    AssessmentFormCompletedInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass-2
    C25367
    Section Ii - Assessments Not Completed
    Descripción

    Section Ii - Assessments Not Completed

    Patient refusal
    Descripción

    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C49161
    UMLS 2011AA Property-3
    C1705116
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Unable to accomodate disability or language needs
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability or language
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Patient did not show up in clinic/office
    Descripción

    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason patient did not show up
    Descripción

    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff unavailable
    Descripción

    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25429
    UMLS 2011AA Property-3
    C0470187
    NCI Metathesaurus Property
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient not given form by staff
    Descripción

    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C25594
    UMLS 2011AA Property-3
    C1518422
    NCI Thesaurus Property-4
    C25382
    UMLS 2011AA Property-4
    C1521801
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient too ill
    Descripción

    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient expired
    Descripción

    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C28554
    UMLS 2011AA Property-3
    C0011065
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Assessment not required per protocol
    Descripción

    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason assessment is not required (If no functioning rectum, please indicate)
    Descripción

    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff thought patient too ill
    Descripción

    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Metathesaurus Property-2
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Descripción

    Quality-of-LifeAssessmentOtherIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Section Iii Assessment Completed
    Descripción

    Section Iii Assessment Completed

    Was Assessment self-administered?
    Descripción

    AssessmentSelf-AdministeredInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25217
    UMLS 2011AA ObjectClass
    C1516048
    NCI Thesaurus Property
    C25670
    UMLS 2011AA Property
    C1519231
    How Was The Patient Assisted
    Descripción

    How Was The Patient Assisted

    Were the questions read aloud to patient
    Descripción

    Quality-of-LifeAssessmentSpeechAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C38025
    UMLS 2011AA Property
    C0037817
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Did the patient require clarification of questions or instructions
    Descripción

    Quality-of-LifeAssessmentDefinitionAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C42777
    UMLS 2011AA Property
    C1704788
    Did the patient require other assistance
    Descripción

    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C25652
    UMLS 2011AA Property-2
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Were the forms completed independently by another person
    Descripción

    Quality-of-LifeAssessmentOtherPersonCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25190
    UMLS 2011AA Property-2
    C0027361
    NCI Thesaurus Property-3
    C25250
    UMLS 2011AA Property-3
    C0205197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    What Was The Reason For Assistance
    Descripción

    What Was The Reason For Assistance

    Did the patient have a language difficulty (questions needed to tbe translated)
    Descripción

    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify language
    Descripción

    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Did the patient have a literacy difficulty (patient could not read well enough)
    Descripción

    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C28020
    UMLS 2011AA Property-2
    C0033213
    NCI Thesaurus Property-3
    C49162
    UMLS 2011AA Property-3
    C0023864
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Was the patient disabled
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Were the forms completed via a telephone interview
    Descripción

    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    NCI Thesaurus Property-2
    C16751
    UMLS 2011AA Property-2
    C0021822
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Descripción

    Quality-of-LifeAssessmentOtherAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Descripción

    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?

    Staff
    Descripción

    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0025106
    Family
    Descripción

    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus Property-3
    C41256
    UMLS 2011AA Property-3
    C0086282
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Friend
    Descripción

    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Metathesaurus Property
    C0079382
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other person
    Descripción

    Quality-of-LifeAssessmentOtherCompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Section Ii - Assessments Not Completed
    Descripción

    Section Ii - Assessments Not Completed

    Patient refusal
    Descripción

    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C49161
    UMLS 2011AA Property-3
    C1705116
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Unable to accomodate disability or language needs
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability or language
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Patient did not show up in clinic/office
    Descripción

    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason patient did not show up
    Descripción

    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff unavailable
    Descripción

    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25429
    UMLS 2011AA Property-3
    C0470187
    NCI Metathesaurus Property
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient not given form by staff
    Descripción

    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C25594
    UMLS 2011AA Property-3
    C1518422
    NCI Thesaurus Property-4
    C25382
    UMLS 2011AA Property-4
    C1521801
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient too ill
    Descripción

    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient expired
    Descripción

    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C28554
    UMLS 2011AA Property-3
    C0011065
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Assessment not required per protocol
    Descripción

    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason assessment is not required (If no functioning rectum, please indicate)
    Descripción

    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff thought patient too ill
    Descripción

    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Metathesaurus Property-2
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherIncompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Descripción

    Quality-of-LifeAssessmentOtherIncompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Section Iii Assessment Completed
    Descripción

    Section Iii Assessment Completed

    Was Assessment self-administered?
    Descripción

    AssessmentSelf-AdministeredInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25217
    UMLS 2011AA ObjectClass
    C1516048
    NCI Thesaurus Property
    C25670
    UMLS 2011AA Property
    C1519231
    How Was The Patient Assisted
    Descripción

    How Was The Patient Assisted

    Were the questions read aloud to patient
    Descripción

    Quality-of-LifeAssessmentSpeechAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C38025
    UMLS 2011AA Property
    C0037817
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Did the patient require clarification of questions or instructions
    Descripción

    Quality-of-LifeAssessmentDefinitionAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C42777
    UMLS 2011AA Property
    C1704788
    Did the patient require other assistance
    Descripción

    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C25652
    UMLS 2011AA Property-2
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Were the forms completed independently by another person
    Descripción

    Quality-of-LifeAssessmentOtherPersonCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25190
    UMLS 2011AA Property-2
    C0027361
    NCI Thesaurus Property-3
    C25250
    UMLS 2011AA Property-3
    C0205197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    What Was The Reason For Assistance
    Descripción

    What Was The Reason For Assistance

    Did the patient have a language difficulty (questions needed to tbe translated)
    Descripción

    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify language
    Descripción

    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Did the patient have a literacy difficulty (patient could not read well enough)
    Descripción

    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C28020
    UMLS 2011AA Property-2
    C0033213
    NCI Thesaurus Property-3
    C49162
    UMLS 2011AA Property-3
    C0023864
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Was the patient disabled
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability
    Descripción

    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Were the forms completed via a telephone interview
    Descripción

    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    NCI Thesaurus Property-2
    C16751
    UMLS 2011AA Property-2
    C0021822
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherAssistanceInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Descripción

    Quality-of-LifeAssessmentOtherAssistanceSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Descripción

    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?

    Staff
    Descripción

    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0025106
    Family
    Descripción

    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus Property-3
    C41256
    UMLS 2011AA Property-3
    C0086282
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Friend
    Descripción

    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Metathesaurus Property
    C0079382
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Descripción

    Quality-of-LifeAssessmentOtherCompleteInd-2

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other person
    Descripción

    Quality-of-LifeAssessmentOtherCompleteSpecify

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Comments
    Descripción

    Comments

    Investigator Signature
    Descripción

    Investigator Signature

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    NCI Thesaurus ObjectClass
    C17089
    Investigator Signature Date
    Descripción

    Investigator Signature Date

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    UMLS CUI-2
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C17089

    Similar models

    INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de datos
    Alias
    Item Group
    ECOG clinical trial administrative data
    Protocol Number ECOG
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Generic drug form
    Item
    DCI Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C3242750 (UMLS CUI-1)
    C19464 (NCI Thesaurus Property)
    C25474 (NCI Thesaurus ObjectClass)
    C25452 (NCI Thesaurus ObjectClass-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Patient ID ECOG
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Item Group
    Patient demographics
    Patient Initials
    Item
    Patient Initials (Last, First)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Protocol Number ECOG
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Study Number Participating Group
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Patient ID ECOG
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    Reporting period
    Item
    On Treatment Report Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25214 (NCI Thesaurus Property)
    C25616 (NCI Thesaurus Property-2)
    C15368 (NCI Thesaurus ObjectClass)
    Code List
    On Treatment Report Period
    CL Item
    Baseline (baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    C25213 (NCI Thesaurus-3)
    C1442488 (UMLS 2011AA-4)
    CL Item
    End Of Cycle 3 (End of Cycle 3)
    CL Item
    End Of Cycle 5 (End of Cycle 5)
    CL Item
    End Of Cycle 6 (End of Cycle 6)
    CL Item
    End Of Cycle 8 (End of Cycle 8)
    CL Item
    End Of Cycle 9 (End of Cycle 9)
    CL Item
    End Of Treatment (End of Treatment)
    Item
    Off Treatment Report Period
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25601 (NCI Thesaurus Property-2)
    C1518544 (UMLS 2011AA Property-2)
    C25207 (NCI Thesaurus Property-3)
    C0040223 (UMLS 2011AA Property-3)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Off Treatment Report Period
    CL Item
    3 Months (3 months post registration)
    CL Item
    6 Months (6 months post registration)
    CL Item
    9 Months (9 months post registration)
    CL Item
    12 Months (12 months post registration)
    CL Item
    15 Months (15 months post registration)
    CL Item
    18 Months (18 months post registration)
    Assessment Date
    Item
    Date of Assessment (If not completed, enter date scheduled per E4A08 protocol.)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2985720 (UMLS CUI-1)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C38000 (NCI Thesaurus Property)
    Item Group
    Section Ii - E1a05 Qol Assessment Not Completed
    AssessmentFormCompletedInd-2
    Item
    Were both of the Assessment Forms completed? (E4A08 Quality of Life)
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ObjectClass-2)
    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2
    Item
    Patient refusal
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C49161 (NCI Thesaurus Property-3)
    C1705116 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2
    Item
    Unable to accomodate disability or language needs
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify
    Item
    Specify disability or language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2
    Item
    Patient did not show up in clinic/office
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify
    Item
    Specify reason patient did not show up
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2
    Item
    Staff unavailable
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25429 (NCI Thesaurus Property-3)
    C0470187 (UMLS 2011AA Property-3)
    C0025106 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2
    Item
    Patient not given form by staff
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C25594 (NCI Thesaurus Property-3)
    C1518422 (UMLS 2011AA Property-3)
    C25382 (NCI Thesaurus Property-4)
    C1521801 (UMLS 2011AA Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2
    Item
    Patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2
    Item
    Patient expired
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C28554 (NCI Thesaurus Property-3)
    C0011065 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2
    Item
    Assessment not required per protocol
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify
    Item
    Specify reason assessment is not required (If no functioning rectum, please indicate)
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2
    Item
    Staff thought patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C0025106 (NCI Metathesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherIncompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherIncompleteSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Section Iii Assessment Completed
    AssessmentSelf-AdministeredInd-2
    Item
    Was Assessment self-administered?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25217 (NCI Thesaurus ObjectClass)
    C1516048 (UMLS 2011AA ObjectClass)
    C25670 (NCI Thesaurus Property)
    C1519231 (UMLS 2011AA Property)
    Item Group
    How Was The Patient Assisted
    Quality-of-LifeAssessmentSpeechAssistanceInd-2
    Item
    Were the questions read aloud to patient
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C38025 (NCI Thesaurus Property)
    C0037817 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentDefinitionAssistanceInd-2
    Item
    Did the patient require clarification of questions or instructions
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C42777 (NCI Thesaurus Property)
    C1704788 (UMLS 2011AA Property)
    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2
    Item
    Did the patient require other assistance
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C25652 (NCI Thesaurus Property-2)
    C1514873 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherPersonCompleteInd-2
    Item
    Were the forms completed independently by another person
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25190 (NCI Thesaurus Property-2)
    C0027361 (UMLS 2011AA Property-2)
    C25250 (NCI Thesaurus Property-3)
    C0205197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item Group
    What Was The Reason For Assistance
    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2
    Item
    Did the patient have a language difficulty (questions needed to tbe translated)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify
    Item
    Specify language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2
    Item
    Did the patient have a literacy difficulty (patient could not read well enough)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property-2)
    C0033213 (UMLS 2011AA Property-2)
    C49162 (NCI Thesaurus Property-3)
    C0023864 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2
    Item
    Was the patient disabled
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify
    Item
    Specify disability
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2
    Item
    Were the forms completed via a telephone interview
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    C16751 (NCI Thesaurus Property-2)
    C0021822 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherAssistanceInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherAssistanceSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2
    Item
    Staff
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0025106 (NCI Metathesaurus Property)
    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2
    Item
    Family
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C41256 (NCI Thesaurus Property-3)
    C0086282 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2
    Item
    Friend
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C0079382 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherCompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherCompleteSpecify
    Item
    Specify other person
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2
    Item
    Patient refusal
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C49161 (NCI Thesaurus Property-3)
    C1705116 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2
    Item
    Unable to accomodate disability or language needs
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify
    Item
    Specify disability or language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2
    Item
    Patient did not show up in clinic/office
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify
    Item
    Specify reason patient did not show up
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2
    Item
    Staff unavailable
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25429 (NCI Thesaurus Property-3)
    C0470187 (UMLS 2011AA Property-3)
    C0025106 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2
    Item
    Patient not given form by staff
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C25594 (NCI Thesaurus Property-3)
    C1518422 (UMLS 2011AA Property-3)
    C25382 (NCI Thesaurus Property-4)
    C1521801 (UMLS 2011AA Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2
    Item
    Patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2
    Item
    Patient expired
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C28554 (NCI Thesaurus Property-3)
    C0011065 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2
    Item
    Assessment not required per protocol
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify
    Item
    Specify reason assessment is not required (If no functioning rectum, please indicate)
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2
    Item
    Staff thought patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C0025106 (NCI Metathesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherIncompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherIncompleteSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Section Iii Assessment Completed
    AssessmentSelf-AdministeredInd-2
    Item
    Was Assessment self-administered?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25217 (NCI Thesaurus ObjectClass)
    C1516048 (UMLS 2011AA ObjectClass)
    C25670 (NCI Thesaurus Property)
    C1519231 (UMLS 2011AA Property)
    Quality-of-LifeAssessmentSpeechAssistanceInd-2
    Item
    Were the questions read aloud to patient
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C38025 (NCI Thesaurus Property)
    C0037817 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentDefinitionAssistanceInd-2
    Item
    Did the patient require clarification of questions or instructions
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C42777 (NCI Thesaurus Property)
    C1704788 (UMLS 2011AA Property)
    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2
    Item
    Did the patient require other assistance
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C25652 (NCI Thesaurus Property-2)
    C1514873 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherPersonCompleteInd-2
    Item
    Were the forms completed independently by another person
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25190 (NCI Thesaurus Property-2)
    C0027361 (UMLS 2011AA Property-2)
    C25250 (NCI Thesaurus Property-3)
    C0205197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item Group
    What Was The Reason For Assistance
    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2
    Item
    Did the patient have a language difficulty (questions needed to tbe translated)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify
    Item
    Specify language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2
    Item
    Did the patient have a literacy difficulty (patient could not read well enough)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property-2)
    C0033213 (UMLS 2011AA Property-2)
    C49162 (NCI Thesaurus Property-3)
    C0023864 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2
    Item
    Was the patient disabled
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify
    Item
    Specify disability
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2
    Item
    Were the forms completed via a telephone interview
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    C16751 (NCI Thesaurus Property-2)
    C0021822 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherAssistanceInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherAssistanceSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2
    Item
    Staff
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0025106 (NCI Metathesaurus Property)
    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2
    Item
    Family
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C41256 (NCI Thesaurus Property-3)
    C0086282 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2
    Item
    Friend
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C0079382 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherCompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherCompleteSpecify
    Item
    Specify other person
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Comments
    Investigator Signature
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    Investigator Signature Date
    Item
    Investigator Signature Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25367 (NCI Thesaurus ValueDomain-2)
    C17089 (NCI Thesaurus ObjectClass)

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