ID

11417

Beskrivning

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

Länk

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

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-07-03 2015-07-03 -
Uppladdad den

3 juli 2015

DOI

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Licens

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

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Header
Beskrivning

Header

SWOG Patient ID
Beskrivning

SWOGPatientID

Datatyp

text

SWOG Study No.
Beskrivning

SWOGStudyNo.

Datatyp

text

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient Initials (L, F M)
Beskrivning

Patient Initials

Datatyp

text

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

Planned Assessment

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

DATE
Beskrivning

FormCompletionDate,Original

Datatyp

date

Physician
Beskrivning

RegisteredInvestigator

Datatyp

text

BY
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

PHONE
Beskrivning

PersonCompletingForm,Phone

Datatyp

text

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

Miscellaneous Patient Information

Was the Pain Medication Log completed?
Beskrivning

PainPersonalLogCompleteInd-3

Datatyp

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?
Beskrivning

WastheBriefPainInventorycompleted?

Datatyp

boolean

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

WastheLASAPatientQualityofLifeQuestionnairecompleted?

Datatyp

boolean

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

Ifcompleted,ingeneral,didthepatientrequireassistance?

Datatyp

boolean

Describe (If Yes,)
Beskrivning

Describe

Datatyp

text

If Completed, Questionnaire administered
Beskrivning

PatientQuestionnaireAdministeredMethodType

Datatyp

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)
Beskrivning

PatientQuestionnaireAdministeredMethodSpecify

Datatyp

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)
Beskrivning

Incomplete documentation, reason

Datatyp

text

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

Other(specify)

Datatyp

text

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

Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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