Description:

E5204 Assessment Compliance Form NCT00303628 Combination Chemotherapy With or Without Bevacizumab in Treating Patients Who Have Had Surgery for Stage II or Stage III Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=08F01694-A022-1380-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=08F01694-A022-1380-E044-0003BA3F9857

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Versions (3) ▾
  1. 8/27/12
  2. 1/9/15
  3. 6/16/15
Uploaded on:

June 16, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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E5204 Assessment Compliance Form NCT00303628

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files.

Header
Patient demographics
Reporting Period
Reporting Period
Data amendment
Section I
Section Ii - Assessments Not Completed
Were all the quality of life forms completed for this timepoint
Section Ii - Assessments Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Other
Fact-gog/ntx: Indicate Reason(s) Why Form Was Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Other
Patient Bowel Function/uniscale Questionnaire: Indicate Reason(s) Why Form Was Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Other
Section Iii - Assessment Completed
Fact-d Subscale: Was Assessment Self-administered?
Was Assessment self-administered?
Fact-gog/ntx: Was Assessment Self-administered?
Was Assessment self-administered?
Patient Bowel Function/uniscale Questionnaire: Was Assessment Self-administered?
Was Assessment self-administered?
How Was The Patient Assisted
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
Fact-gog/ntx: How Was The Patient Assisted?
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
Patient Bowel Function/uniscale Questionnaire: How Was The Patient Assisted?
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
What Was The Reason For Assistance
Did the patient have a language difficulty (questions needed to be translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Other
Fact-gog/ntx: What Was The Reason For Assistance?
Did the patient have a language difficulty (questions needed to be translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Other
Patient Bowel Function/uniscale Questionnaire: What Was The Reason For Assistance?
Did the patient have a language difficulty (questions needed to be translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Other
Who Assisted Or Completed Assessment
Staff
Family
Friend
Other
Fact-gog/ntx: Who Assisted Or Completed Assessment?
Staff
Family
Friend
Other
Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
Staff
Family
Friend
Other