ID

11417

Descrição

NCT00075686 COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205 S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B186CE8D-98A1-0591-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B186CE8D-98A1-0591-E034-0003BA12F5E7

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 03/07/2015 03/07/2015 -
Transferido a

3 de julho de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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NCT00075686 COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Header
Descrição

Header

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient Initials (L, F M)
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Planned Assessment
Descrição

Planned Assessment

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

DATE
Descrição

FormCompletionDate,Original

Tipo de dados

date

Physician
Descrição

RegisteredInvestigator

Tipo de dados

text

BY
Descrição

PersonCompletingForm,LastName

Tipo de dados

text

PHONE
Descrição

PersonCompletingForm,Phone

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Miscellaneous Patient Information
Descrição

Miscellaneous Patient Information

Was the Pain Medication Log completed?
Descrição

PainPersonalLogCompleteInd-3

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C3303
UMLS 2011AA ObjectClass
C0030193
NCI Metathesaurus ObjectClass
C0872075
Was the Brief Pain Inventory completed?
Descrição

WastheBriefPainInventorycompleted?

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Was the LASA Patient Quality of Life Questionnaire completed?
Descrição

WastheLASAPatientQualityofLifeQuestionnairecompleted?

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Completed, In general did the patient require assistance?
Descrição

Ifcompleted,ingeneral,didthepatientrequireassistance?

Tipo de dados

boolean

Describe (If Yes,)
Descrição

Describe

Tipo de dados

text

If Completed, Questionnaire administered
Descrição

PatientQuestionnaireAdministeredMethodType

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C17048
UMLS 2011AA ObjectClass-2
C0034394
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other (please specify)
Descrição

PatientQuestionnaireAdministeredMethodSpecify

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C17048
UMLS 2011AA ObjectClass-2
C0034394
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
If Not completed, Please give reason (select one)
Descrição

Incomplete documentation, reason

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS CUI-1
C1548386
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C0566251
NCI Metathesaurus Property
C0034394
Other (specify)
Descrição

Other(specify)

Tipo de dados

text

Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205
Descrição

Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item
Planned Assessment
text
CL.1
Code List
Planned Assessment
CL Item
Prestudy (Prestudy)
CL Item
Week 5 (Week 5)
CL Item
Week 9 (Week 9)
CL Item
Week 13 (Week 13)
CL Item
Week 17 (Week 17)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
FormCompletionDate,Original
Item
DATE
date
RegisteredInvestigator
Item
Physician
text
PersonCompletingForm,LastName
Item
BY
text
PersonCompletingForm,Phone
Item
PHONE
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item Group
Miscellaneous Patient Information
PainPersonalLogCompleteInd-3
Item
Was the Pain Medication Log completed?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C3303 (NCI Thesaurus ObjectClass)
C0030193 (UMLS 2011AA ObjectClass)
C0872075 (NCI Metathesaurus ObjectClass)
WastheBriefPainInventorycompleted?
Item
Was the Brief Pain Inventory completed?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
WastheLASAPatientQualityofLifeQuestionnairecompleted?
Item
Was the LASA Patient Quality of Life Questionnaire completed?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Ifcompleted,ingeneral,didthepatientrequireassistance?
Item
If Completed, In general did the patient require assistance?
boolean
Describe
Item
Describe (If Yes,)
text
Item
If Completed, Questionnaire administered
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus ObjectClass-2)
C0034394 (UMLS 2011AA ObjectClass-2)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
If Completed, Questionnaire administered
CL Item
In The Clinic (In the clinic)
CL Item
By Telephone (By telephone)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientQuestionnaireAdministeredMethodSpecify
Item
Other (please specify)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus ObjectClass-2)
C0034394 (UMLS 2011AA ObjectClass-2)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
If Not completed, Please give reason (select one)
text
C25638 (NCI Thesaurus ValueDomain)
C1548386 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C0566251 (UMLS CUI-2)
C0034394 (NCI Metathesaurus Property)
CL.7
Code List
If Not completed, Please give reason (select one)
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Not Illness Related (Not illness related)
CL Item
Institution Error (Institution error)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other(specify)
Item
Other (specify)
text
Item Group
Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205
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