ID

11155

Descrição

RTOG-0522 QP: Radiation Therapy Oncology Group Miscellaneous Patient Assessment Form NCT00265941 Radiation Therapy and Cisplatin With or Without Cetuximab in Treating Patients With Stage III or Stage IV Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F6217E11-C5E7-5543-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F6217E11-C5E7-5543-E034-0003BA3F9857

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 21/06/2015 21/06/2015 -
Transferido a

21 de junho de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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RTOG-0522 QP: Miscellaneous Patient Assessment Form NCT00265941

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: RTOG-0522 QP: Miscellaneous Patient Assessment Form
    1. No Instruction available.
RTOG clinical trial administrative data
Descrição

RTOG clinical trial administrative data

RTOG Study No.
Descrição

Protocol ID RTOG

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Descrição

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
Institution Name
Descrição

Institution Name

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Descrição

Institution Number

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Patient Initials
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Descrição

Trial subject ID RTOG

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Miscellaneous Patient Assessment
Descrição

Miscellaneous Patient Assessment

SCHEDULED DATA POINT (CHECK ONE)
Descrição

DataAssessmentTimePeriodType

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
other followup
Descrição

DataAssessmentTimePeriodUnspecifiedText

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Other, specify
Descrição

DataAssessmentTimePeriodOtherText

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
Descrição

AssessmentNotPerformedReason

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus ObjectClass
C25217
UMLS 2011AA ObjectClass
C1516048
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
Patient refused, including attempts by telephone interview, specify reason for refusal
Descrição

PatientTelephoneAssessmentRefusaltoParticipateReason

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
Patient refused, telephone interview not attempted, specify reason for refusal
Descrição

PatientAssessmentRefusaltoParticipateReason

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Other reason, specify
Descrição

OtherPatientAssessmentRefusaltoParticipateReason

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass-2
C16960
UMLS 2011AA ObjectClass-2
C0030705
NCI Thesaurus Property
C25367
WAS INFORMATION OBTAINED BY TELEPHONE INTERVIEW (CHECK ONE)
Descrição

PatientTelephoneAssessmentInd-2

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
DATE OF EVALUATION
Descrição

LesionAssessmentDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain-2
C25367
RATER'S NAME
Descrição

PatientTelephoneAssessmentInterviewersName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
Normalcy of Diet Rating
Descrição

DietPerformanceStatusAssessmentIntakeScale

Tipo de dados

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25538
UMLS 2011AA ValueDomain-2
C1512806
Public Eating Rating
Descrição

DietaryPerformanceStatusAssessmentLocationScale

Tipo de dados

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25341
UMLS 2011AA ValueDomain-2
C0450429
Understandability of Speech Rating
Descrição

SpeechPerformanceStatusAssessmentComprehensionScale

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C38025
UMLS 2011AA ObjectClass
C0037817
NCI Metathesaurus ObjectClass
CL092952
Comments
Descrição

Comments

COMMENTS
Descrição

Research Comments

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Responsible Person Signature Text
Descrição

Responsible Person Signature

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Date Form Originally Completed
Descrição

Form Completion Date

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
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1 Formulários
  1. StudyEvent: RTOG-0522 QP: Miscellaneous Patient Assessment Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
RTOG clinical trial administrative data
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Miscellaneous Patient Assessment
Item
SCHEDULED DATA POINT (CHECK ONE)
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.1
Code List
SCHEDULED DATA POINT (CHECK ONE)
CL Item
Pre Treatment Assessment (Pre treatment assessment)
CL Item
At Completion Of Radiotherapy (At completion of radiotherapy)
CL Item
Other Followup (other followup)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
DataAssessmentTimePeriodUnspecifiedText
Item
other followup
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
DataAssessmentTimePeriodOtherText
Item
Other, specify
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
Item
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C25217 (NCI Thesaurus ObjectClass)
C1516048 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
CL.2
Code List
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
CL Item
Patient Was Too Ill (Patient was too ill)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Questionnaire Not Completed Due To Institutional Error (Questionnaire not completed due to institutional error)
CL Item
Patient Refused, Including Attempts By Telephone Interview (Patient refused, including attempts by telephone interview)
CL Item
Patient Refused, Telephone Interview Not Attempted (Patient refused, telephone interview not attempted)
CL Item
Other Reason (Other reason)
PatientTelephoneAssessmentRefusaltoParticipateReason
Item
Patient refused, including attempts by telephone interview, specify reason for refusal
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
PatientAssessmentRefusaltoParticipateReason
Item
Patient refused, telephone interview not attempted, specify reason for refusal
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
OtherPatientAssessmentRefusaltoParticipateReason
Item
Other reason, specify
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass-2)
C0030705 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
PatientTelephoneAssessmentInd-2
Item
WAS INFORMATION OBTAINED BY TELEPHONE INTERVIEW (CHECK ONE)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
LesionAssessmentDate
Item
DATE OF EVALUATION
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain-2)
PatientTelephoneAssessmentInterviewersName
Item
RATER'S NAME
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
Item
Normalcy of Diet Rating
text
CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25538 (NCI Thesaurus ValueDomain-2)
C1512806 (UMLS 2011AA ValueDomain-2)
CL.4
Code List
Normalcy of Diet Rating
CL Item
0= Non-oral Feeding (tube Fed) (0)
CL Item
10= Cold Liquids (10)
CL Item
100= Full Diet (no Restrictions) (100)
CL Item
20= Warm Liquids (20)
CL Item
30= Pureed Foods (in Blender) (30)
CL Item
40= Soft Foods Requiring No Chewing (e.g., Mashed Potatoes, Apple Sauce, Pudding) (40)
CL Item
50= Soft, Chewable Foods (e.g., Macaroni, Canned/soft Fruits, Cooked Vegetables, Fish, Hamburger, Small Pieces Of Meat) (50)
CL Item
60= Dry Bread And Crackers (60)
CL Item
70= Raw Carrots, Celery (70)
CL Item
80= All Meat (80)
CL Item
90= Full Diet (liquid Assist) (90)
Item
Public Eating Rating
text
CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus ValueDomain-2)
C0450429 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Public Eating Rating
CL Item
0= Always Eats Alone (0)
CL Item
100= No Restriction Of Place, Food Or Companion (eats Out At Any Opportunity) (100)
CL Item
25= Eats Only At Home In Presence Of Selected Persons (25)
CL Item
50= Eats Only In Presence Of Selected Persons In Selected Places (50)
CL Item
75= No Restriction Of Place, But Restricts Diet When In Public (eats Anywhere, But May Limit Intake To Less "messy" Foods, E.g., Liquids) (75)
Item
Understandability of Speech Rating
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C38025 (NCI Thesaurus ObjectClass)
C0037817 (UMLS 2011AA ObjectClass)
CL092952 (NCI Metathesaurus ObjectClass)
CL.6
Code List
Understandability of Speech Rating
CL Item
0= Never Understandable; May Use Written Communication (0)
CL Item
100= Always Understandable (100)
CL Item
25= Difficult To Understand (25)
CL Item
50= Usually Understandable; Face-to-face Contact Necessary (50)
CL Item
75= Understandable Most Of The Time; Occasional Repetition Necessary (75)
Item Group
Comments
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Responsible Person Signature
Item
Responsible Person Signature Text
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Form Completion Date
Item
Date Form Originally Completed
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
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