ID

11116

Description

CALGB-10501 Impact Of Event Scale- Revised Form NCT00513747 Early or Delayed Fludarabine and Rituximab in Treating Patients With Previously Untreated Chronic Lymphocytic Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=340EF355-2CAB-21DF-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=340EF355-2CAB-21DF-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/18/15 6/18/15 -
Uploaded on

June 18, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

CALGB-10501 Impact Of Event Scale- Revised Form NCT00513747

English

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms  
Header
Description

Header

CALGB Form
Description

Form ID CALGB

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3262252
NCI Thesaurus ObjectClass
C19464
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C25442
CALGB Study No
Description

Protocol ID CALGB

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
CALGB Patient ID
Description

Trial subject ID CALGB

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
Are data amended
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Patient demographics
Description

Patient demographics

Patient Initials (Last, First Middle)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Hospital No.
Description

Medical Record Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
Institution/Affiliate
Description

Institution Name

Data type

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
Participating Group
Description

Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Group Study No
Description

Study Number Participating Group

Data type

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
Participating Group Patient ID
Description

Trial subject ID Participating Group

Data type

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
Visit number
Description

Visit number

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1549755
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
Impact Of Event
Description

Impact Of Event

Any reminder brought back feelings about it
Description

EmotionReminderPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C54266
UMLS 2011AA ObjectClass-2
C0013987
NCI Thesaurus ObjectClass-3
C54270
UMLS 2011AA ObjectClass-3
C1709896
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
I had trouble staying asleep
Description

PatientDifficultySleepingAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C73425
UMLS 2011AA Property
C0037313
NCI Thesaurus Property-3
C62189
UMLS 2011AA Property-2
C1299586
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Other things kept making me think about it
Description

ThinkingReminderPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C54270
UMLS 2011AA ObjectClass-2
C1709896
NCI Thesaurus ObjectClass-3
C54226
UMLS 2011AA ObjectClass-3
C0039869
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
I thought about it when I didn't mean to
Description

ThinkingReminderAccidentPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C34340
UMLS 2011AA ObjectClass-2
C0000924
NCI Thesaurus ObjectClass-3
C54270
UMLS 2011AA ObjectClass-3
C1709896
NCI Thesaurus ObjectClass-4
C54226
UMLS 2011AA ObjectClass-4
C0039869
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Pictures about it popped into my mind
Description

ThinkingPictureReminderPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C54270
UMLS 2011AA ObjectClass-2
C1709896
NCI Thesaurus ObjectClass-3
C54226
UMLS 2011AA ObjectClass-3
C0039869
NCI Thesaurus ObjectClass-4
C54273
UMLS 2011AA ObjectClass-4
C0441469
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
I had waves of strong feelings about it
Description

EmotionStrongPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C54266
UMLS 2011AA ObjectClass-2
C0013987
NCI Thesaurus ObjectClass-3
C62223
UMLS 2011AA ObjectClass-3
C0442821
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
I had dreams about it
Description

DreamingPersonLifeDistressAssessmentScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C54268
UMLS 2011AA ObjectClass-2
C0013117
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C37987
UMLS 2011AA Property
C0376558
NCI Thesaurus Property-3
C37942
UMLS 2011AA Property-2
C0231303
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Overall Response
Description

Overall Response

Completed by (print or type name)
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date Form Completed (MM DD YYYY)
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
Back to the top of the page

Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Form ID CALGB
Item
CALGB Form
text
C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
Protocol ID CALGB
Item
CALGB Study No
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Data amended
Item
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Patient demographics
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (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)
Participating Group
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No
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)
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)
Visit number
Item
Visit number
float
C25337 (NCI Thesaurus ValueDomain)
C1549755 (UMLS CUI-1)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
Item Group
Impact Of Event
Item
Any reminder brought back feelings about it
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C54266 (NCI Thesaurus ObjectClass-2)
C0013987 (UMLS 2011AA ObjectClass-2)
C54270 (NCI Thesaurus ObjectClass-3)
C1709896 (UMLS 2011AA ObjectClass-3)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.2
Code List
Any reminder brought back feelings about it
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item
I had trouble staying asleep
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C73425 (NCI Thesaurus Property-2)
C0037313 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property-3)
C1299586 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.3
Code List
I had trouble staying asleep
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
CL Item
A Little Bit (A little bit)
CL Item
Moderately (Moderately)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Extremely (Extremely)
Item
Other things kept making me think about it
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C54270 (NCI Thesaurus ObjectClass-2)
C1709896 (UMLS 2011AA ObjectClass-2)
C54226 (NCI Thesaurus ObjectClass-3)
C0039869 (UMLS 2011AA ObjectClass-3)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.4
Code List
Other things kept making me think about it
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item
I thought about it when I didn't mean to
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C34340 (NCI Thesaurus ObjectClass-2)
C0000924 (UMLS 2011AA ObjectClass-2)
C54270 (NCI Thesaurus ObjectClass-3)
C1709896 (UMLS 2011AA ObjectClass-3)
C54226 (NCI Thesaurus ObjectClass-4)
C0039869 (UMLS 2011AA ObjectClass-4)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.5
Code List
I thought about it when I didn't mean to
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item
Pictures about it popped into my mind
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C54270 (NCI Thesaurus ObjectClass-2)
C1709896 (UMLS 2011AA ObjectClass-2)
C54226 (NCI Thesaurus ObjectClass-3)
C0039869 (UMLS 2011AA ObjectClass-3)
C54273 (NCI Thesaurus ObjectClass-4)
C0441469 (UMLS 2011AA ObjectClass-4)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.6
Code List
Pictures about it popped into my mind
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item
I had waves of strong feelings about it
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C54266 (NCI Thesaurus ObjectClass-2)
C0013987 (UMLS 2011AA ObjectClass-2)
C62223 (NCI Thesaurus ObjectClass-3)
C0442821 (UMLS 2011AA ObjectClass-3)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.7
Code List
I had waves of strong feelings about it
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item
I had dreams about it
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C54268 (NCI Thesaurus ObjectClass-2)
C0013117 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C37987 (NCI Thesaurus Property-2)
C0376558 (UMLS 2011AA Property)
C37942 (NCI Thesaurus Property-3)
C0231303 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.8
Code List
I had dreams about it
CL Item
A Little Bit (A little bit)
CL Item
Extremely (Extremely)
CL Item
Moderately (Moderately)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
Item Group
Overall Response
Person Completing Form
Item
Completed by (print or type name)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Date Form Completed
Item
Date Form Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial