ID

11310

Beschrijving

CALGB: QOL ASSESSMENT SUMMARY FORM [803030] NCT00088894 Gemcitabine With or Without Bevacizumab in Treating Patients With Locally Advanced or Metastatic Pancreatic Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D5EBCEB3-8BEC-0795-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D5EBCEB3-8BEC-0795-E034-0003BA12F5E7

Trefwoorden

Versies (4)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
  4. 29-06-15 29-06-15 -
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29 juni 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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CALGB: QOL ASSESSMENT SUMMARY FORM [803030] NCT00088894

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: CALGB: QOL ASSESSMENT SUMMARY FORM [803030]
    1. No Instruction available.
Header
Beschrijving

Header

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
Date Completed
Beschrijving

Form Completion Date

Datatype

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
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's Name
Beschrijving

Patient Name

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1299487
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
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
Patient Hospital Number
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
Participating Group Protocol 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
Main Member Institution/Adjunct
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 Patient No.
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
Method of Evaluation
Beschrijving

Method of Evaluation

Method of assessment
Beschrijving

Methodofassessment

Datatype

text

date questionnaire was sent to patient
Beschrijving

datequestionnairewassenttopatient

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Number of attempts made to contact patient by telephone and/or mail
Beschrijving

Numberofattemptsmadetocontactpatientbytelephoneand/ormail

Datatype

float

Language in which assessment was conducted
Beschrijving

Languageinwhichassessmentwasconducted

Datatype

text

Other, specify
Beschrijving

Other,specify(languageinwhichassessmentwasconducted)

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Quality of life assessment
Beschrijving

Qualityoflifeassessment

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
number of QOL instrument(s) completed
Beschrijving

numberofQOLinstrument(s)completed

Datatype

float

indicate reasons(s) below (If the assessment was partially completed or not done,)
Beschrijving

Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below

Datatype

text

Other, specify
Beschrijving

Other,specify(reasonassessmentwaspartiallycompletedornotdone)

Datatype

text

Footer module
Beschrijving

Footer module

Interviewer OR CRA
Beschrijving

Person Completing Form

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Assessment Number
Beschrijving

TreatmentReportingPeriodNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25651
UMLS 2011AA Property-2
C0700287
Comments
Beschrijving

Comments

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: CALGB: QOL ASSESSMENT SUMMARY FORM [803030]
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
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)
Form Completion Date
Item
Date 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)
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 Name
Item
Patient's Name
text
C25191 (NCI Thesaurus ValueDomain)
C1299487 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
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)
Medical Record Number
Item
Patient Hospital Number
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)
Study Number Participating Group
Item
Participating Group Protocol 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)
Institution Name
Item
Main Member Institution/Adjunct
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)
Trial subject ID Participating Group
Item
Participating Group Patient No.
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
Method of Evaluation
Item
Method of assessment
text
CL.2
Code List
Method of assessment
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
CL Item
Telephone Interview (Telephone interview)
CL Item
Mailed Questionnaire (Mailed questionnaire)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
float
Item
Language in which assessment was conducted
text
CL.3
Code List
Language in which assessment was conducted
CL Item
English (English)
C43853 (NCI Thesaurus)
C1556083 (UMLS 2011AA)
CL Item
Spanish (Spanish)
CL Item
French (French)
CL Item
Other, Specify (Other, specify)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Quality of life assessment
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
CL.4
Code List
Quality of life assessment
CL Item
Completed (Completed)
CL Item
Partially Completed (Partially completed)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
float
Item
indicate reasons(s) below (If the assessment was partially completed or not done,)
text
CL.5
Code List
indicate reasons(s) below (If the assessment was partially completed or not done,)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
CL Item
Patient Too Medically Ill (Patient too medically ill)
CL Item
Patient Died (Patient died)
CL Item
Patient Refuses (Patient refuses)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify
text
Item Group
Footer module
Person Completing Form
Item
Interviewer OR CRA
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
TreatmentReportingPeriodNumber
Item
Assessment Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
Comments
Item
Comments
text
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