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ID
11426
Description
NCT00075686 COVER SHEET 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=A6631050-8DCA-48C7-E034-0003BA0B1A09
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Keywords
Versions (3)
- 9/20/12 9/20/12 -
- 1/9/15 1/9/15 - Martin Dugas
- 7/3/15 7/3/15 -
Uploaded on
July 3, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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NCT00075686 COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
No Instruction available.
- StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
Similar models
No Instruction available.
- StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
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)
InstitutionName
Item
Institution
text
AffiliateName
Item
Affiliate
text
RegisteredInvestigator
Item
Physician
text
PersonCompletingForm,LastName
Item
BY
text
PersonCompletingForm,Phone
Item
PHONE
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
FormCompletionDate,Original
Item
DATE
date
WastheBriefPainInventorycompleted?
Item
Was the Brief Pain Inventory completed?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
SymptomAssessmentDate
Item
Date (1.)
date
Item
Which types of assistance were required? (select all that apply)
text
CL Item
No Assistance Required (No assistance required)
CL Item
Asked To Explain Meaning Of Terms (Asked to explain meaning of terms)
CL Item
Asked For Help With The Response Format (Asked for help with the response format)
CL Item
Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions. (Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions.)
CL Item
Needed Questionnaire Read Aloud But Able To Answer Questions On His/her Own (Needed questionnaire read aloud but able to answer questions on his/her own)
CL Item
Needed Questionnaire Read Aloud And Needed Nurse/cra To Write Patient Verbal Answers On Form (Needed questionnaire read aloud and needed nurse/CRA to write patient verbal answers on form)
CL Item
Other (specify) (Other (specify))
Other(specify)
Item
Other (specify)
text
Item
If the Brief Pain Inventory Not completed, Please give reason (select one)
text
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Institution Error (Institution error)
CL Item
Not Illness Related (Not illness related)
CL Item
Other (specify) (Other (specify))
LymphNodeSamplingOtherExtent
Item
Other (specify)
text
WastheLASAPatientQualityofLifeQuestionnairecompleted?
Item
Was the LASA Patient Quality of Life Questionnaire completed? (If Yes,)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
text
Code List
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Institution Error (Institution error)
CL Item
Not Illness Related (Not illness related)
CL Item
Other (specify) (Other (specify))