ID

11116

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 18-06-15 18-06-15 -
Geüploaded op

18 juni 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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CALGB-10501 Impact Of Event Scale- Revised Form NCT00513747

Engels

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 Formulieren  
Header
Beschrijving

Header

CALGB Form
Beschrijving

Form ID CALGB

Datatype

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
Beschrijving

Protocol ID CALGB

Datatype

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
Beschrijving

Trial subject ID CALGB

Datatype

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
Beschrijving

Data amended

Datatype

boolean

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

Patient demographics

Patient Initials (Last, First Middle)
Beschrijving

Patient Initials

Datatype

text

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

Medical Record Number

Datatype

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
Beschrijving

Institution Name

Datatype

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
Beschrijving

Participating Group

Datatype

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
Beschrijving

Study Number Participating Group

Datatype

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
Beschrijving

Trial subject ID Participating Group

Datatype

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
Beschrijving

Visit number

Datatype

float

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

Impact Of Event

Any reminder brought back feelings about it
Beschrijving

EmotionReminderPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

PatientDifficultySleepingAssessmentScale

Datatype

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
Beschrijving

ThinkingReminderPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

ThinkingReminderAccidentPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

ThinkingPictureReminderPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

EmotionStrongPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

DreamingPersonLifeDistressAssessmentScale

Datatype

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
Beschrijving

Overall Response

Completed by (print or type name)
Beschrijving

Person Completing Form

Datatype

text

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

Date Form Completed

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
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