CALGB-10501 Family History Questionnaire Form NCT00513747

ID

11368

Beschreibung

CALGB-10501 Family History Questionnaire 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=3410315B-B48B-28F5-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3410315B-B48B-28F5-E044-0003BA3F9857

Stichworte

Klinische Studie [Dokumenttyp]

Demographie

Leukämie

Hochgeladen am

3. Juli 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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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 Formulare

StudyEvent: CALGB-10501 Family History Questionnaire Form
1. 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

Header

Beschreibung

Header

CALGB Form

Beschreibung

Form ID CALGB

Datentyp

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

Beschreibung

Protocol ID CALGB

Datentyp

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

Beschreibung

Trial subject ID CALGB

Datentyp

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 Form Completed

Beschreibung

Date Form Completed

Datentyp

date

Alias

NCI Thesaurus ValueDomain: C25164

UMLS CUI-1: C1115437

NCI Thesaurus ObjectClass: C40988

NCI Thesaurus Property: C25250

NCI Thesaurus ValueDomain-2: C25367

Are data amended

Beschreibung

Data amended

Datentyp

boolean

Alias

NCI Thesaurus ValueDomain: C38148

UMLS CUI-1: C0680532

NCI Thesaurus ObjectClass: C25474

NCI Thesaurus Property: C25416

Yes

Patient demographics

Beschreibung

Patient demographics

Patient Initials (Last, First Middle)

Beschreibung

Patient Initials

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C2986440

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25536

Patient Hospital No.

Beschreibung

Medical Record Number

Datentyp

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

Beschreibung

Institution Name

Datentyp

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

Beschreibung

Participating Group

Datentyp

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

Beschreibung

Study Number Participating Group

Datentyp

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

Beschreibung

Trial subject ID Participating Group

Datentyp

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

If you do not wish to answer any of the following questions, please mark with an 'X.'

Beschreibung

QuestionnaireAssessmentNotPerformedText

Datentyp

text

Alias

NCI Thesaurus ObjectClass: C17048

UMLS 2011AA ObjectClass: C0034394

NCI Thesaurus ObjectClass-2: C25367

NCI Thesaurus Property: C25594

UMLS 2011AA Property: C1518422

NCI Thesaurus Property-2: C38000

UMLS 2011AA Property-2: C0884358

NCI Thesaurus ValueDomain: C25704

UMLS 2011AA ValueDomain: C1527021

Overall Response

Beschreibung

Overall Response

Can we contact you in the future by mail, telephone or e-mail

Beschreibung

Permission to contact Patient

Datentyp

boolean

Alias

NCI Thesaurus ObjectClass: C16960

UMLS CUI-1: C1522577

NCI Thesaurus Property: C67527

UMLS CUI-2: C0521104

NCI Thesaurus Property-2: C25460

NCI Thesaurus Property-3: C16452

NCI Thesaurus ValueDomain: C38148

Yes

Phone

Beschreibung

Person Completing Form Phone

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C1550483

NCI Thesaurus ObjectClass: C25190

UMLS CUI-2: C1515258

NCI Thesaurus ObjectClass-2: C25657

NCI Thesaurus Property: C25395

Email Address

Beschreibung

ResponsiblePersonE-mailAddressText

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25704

UMLS 2011AA ValueDomain: C1527021

NCI Thesaurus ObjectClass: C25657

UMLS 2011AA ObjectClass: C1273518

NCI Thesaurus Property: C42775

UMLS 2011AA Property: C1705961

Comments

Beschreibung

Research Comments

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25704

UMLS CUI-1: C0947611

NCI Thesaurus ObjectClass: C15319

NCI Thesaurus Property: C25393

Zum Seitenanfang zurückkehren

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 Formulare

StudyEvent: CALGB-10501 Family History Questionnaire Form
1. 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

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Header

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)

Date Form Completed

Item

Date Form Completed

date

C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
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)

Patient demographics

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)

QuestionnaireAssessmentNotPerformedText

Item

If you do not wish to answer any of the following questions, please mark with an 'X.'

text

C17048 (NCI Thesaurus ObjectClass)
C0034394 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

Family history

Item Group

Family history

RelativeFamilyCancerHistoryInd-3

Item

Have any of your blood relatives ever been diagnosed with cancer

text

C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus ObjectClass-2)
C0080103 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.2

Code List

Have any of your blood relatives ever been diagnosed with cancer

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

RelativeFamilyCancerHistoryType

Item

Blood relative with cancer

text

C25173 (NCI Thesaurus ObjectClass)
C0015576 (UMLS 2011AA ObjectClass)
C21480 (NCI Thesaurus ObjectClass-2)
C0080103 (UMLS 2011AA ObjectClass-2)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.3

Code List

Blood relative with cancer

CL Item

Aunt #1 (Aunt #1)

CL Item

Aunt #2 (Aunt #2)

CL Item

Aunt #3 (Aunt #3)

CL Item

Aunt #4 (Aunt #4)

CL Item

Brother #1 (Brother #1)

CL Item

Brother #2 (Brother #2)

CL Item

Brother #3 (Brother #3)

CL Item

Brother #4 (Brother #4)

CL Item

Child #1 (Child #1)

CL Item

Child #2 (Child #2)

CL Item

Child #3 (Child #3)

CL Item

Child #4 (Child #4)

CL Item

Cousin #1 (Cousin #1)

CL Item

Cousin #2 (Cousin #2)

CL Item

Cousin #3 (Cousin #3)

CL Item

Cousin #4 (Cousin #4)

CL Item

Father (Father)

C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)

CL Item

Mother (Mother)

C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)

CL Item

Sister #1 (Sister #1)

CL Item

Sister #2 (Sister #2)

CL Item

Sister #3 (Sister #3)

CL Item

Sister #4 (Sister #4)

CL Item

Uncle #1 (Uncle #1)

CL Item

Uncle #2 (Uncle #2)

CL Item

Uncle #3 (Uncle #3)

CL Item

Uncle #4 (Uncle #4)

Patient Status

Item

Vital Status

text

C16960 (NCI Thesaurus ObjectClass)
C3846084 (UMLS CUI-1)
C18003 (NCI Thesaurus ValueDomain)
C25688 (NCI Thesaurus ValueDomain-2)
C25717 (NCI Thesaurus Property)

CL.4

Code List

Vital Status

CL Item

Dead (Dead)

CL Item

Alive (Alive)

CancerSiteType

Item

Type of Cancer

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)

CL.5

Code List

Type of Cancer

CL Item

Breast (Breast)

C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)

CL Item

Cll (CLL)

C3163 (NCI Thesaurus)
C0023434 (UMLS 2011AA)

CL Item

Colon (Colon)

C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)

CL Item

Head & Neck (Head & Neck)

CL Item

Hodgkin's Lymphoma (Hodgkin's lymphoma)

C9357 (NCI Thesaurus)
C0019829 (UMLS 2011AA)

CL Item

Lung (Lung)

C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)

CL Item

Non Melanoma Skin (Non Melanoma Skin)

CL Item

Non-hodgkin's Lymphoma (Non-Hodgkin's lymphoma)

C3211 (NCI Thesaurus)
C0024305 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

Prostate (Prostate)

C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)

CancerSiteSpecify

Item

Specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)

MalignantNeoplasmSiblingsPresentNumber

Item

Total number of siblings with cancer

float

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25204 (NCI Thesaurus Property-2)
C0037047 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25304 (NCI Thesaurus ValueDomain-2)
C0439810 (UMLS 2011AA ValueDomain-2)

MalignantNeoplasmSiblingsAbsentNumber

Item

Total number of siblings without cancer

float

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25204 (NCI Thesaurus Property-2)
C0037047 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25304 (NCI Thesaurus ValueDomain-2)
C0439810 (UMLS 2011AA ValueDomain-2)

MalignantNeoplasmChildPresentNumber

Item

Total number of children with cancer

float

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C16423 (NCI Thesaurus Property-2)
C0008059 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25304 (NCI Thesaurus ValueDomain-2)
C0439810 (UMLS 2011AA ValueDomain-2)

MalignantNeoplasmChildAbsentNumber

Item

Total number of children without cancer

float

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C16423 (NCI Thesaurus Property-2)
C0008059 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25304 (NCI Thesaurus ValueDomain-2)
C0439810 (UMLS 2011AA ValueDomain-2)

Contact Information/Comments

Item Group

Overall Response

Permission to contact Patient

Item

Can we contact you in the future by mail, telephone or e-mail

boolean

C16960 (NCI Thesaurus ObjectClass)
C1522577 (UMLS CUI-1)
C67527 (NCI Thesaurus Property)
C0521104 (UMLS CUI-2)
C25460 (NCI Thesaurus Property-2)
C16452 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)

Person Completing Form Phone

Item

Phone

text

C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)

ResponsiblePersonE-mailAddressText

Item

Email Address

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS 2011AA Property)

Research Comments

Item

Comments

text

C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

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ID

Beschreibung

Link

Stichworte

Versionen (4)

Hochgeladen am

DOI

Lizenz

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Itemgroup Kommentare für :

Item Kommentare für :

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

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