ID

11426

Beschreibung

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

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6631050-8DCA-48C7-E034-0003BA0B1A09

Stichworte

Versionen (3)
  1. 20.09.12 20.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 03.07.15 03.07.15 -
Hochgeladen am

3. Juli 2015

DOI

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Lizenz

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

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Header
Beschreibung

Header

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F M)
Beschreibung

Patient Initials

Datentyp

text

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

Planned Assessment

Datentyp

text

Institution
Beschreibung

InstitutionName

Datentyp

text

Affiliate
Beschreibung

AffiliateName

Datentyp

text

Physician
Beschreibung

RegisteredInvestigator

Datentyp

text

BY
Beschreibung

PersonCompletingForm,LastName

Datentyp

text

PHONE
Beschreibung

PersonCompletingForm,Phone

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
DATE
Beschreibung

FormCompletionDate,Original

Datentyp

date

Miscellaneous Patient Information
Beschreibung

Miscellaneous Patient Information

Was the Brief Pain Inventory completed?
Beschreibung

WastheBriefPainInventorycompleted?

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date (1.)
Beschreibung

SymptomAssessmentDate

Datentyp

date

Which types of assistance were required? (select all that apply)
Beschreibung

Whichtypesofassistancewererequired?

Datentyp

text

Other (specify)
Beschreibung

Other(specify)

Datentyp

text

If the Brief Pain Inventory Not completed, Please give reason (select one)
Beschreibung

IftheBriefPainInventoryNotcompleted,Pleasegivereason

Datentyp

text

Other (specify)
Beschreibung

LymphNodeSamplingOtherExtent

Datentyp

text

Was the LASA Patient Quality of Life Questionnaire completed? (If Yes,)
Beschreibung

WastheLASAPatientQualityofLifeQuestionnairecompleted?

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
Beschreibung

IfLASAPatientQualityofLifeQuestionnaireNotcompleted,Pleasegivereason

Datentyp

text

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
Beschreibung

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
Beschreibung

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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)
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)
FormCompletionDate,Original
Item
DATE
date
Item Group
Miscellaneous Patient Information
WastheBriefPainInventorycompleted?
Item
Was the Brief Pain Inventory completed?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
SymptomAssessmentDate
Item
Date (1.)
date
Item
Which types of assistance were required? (select all that apply)
text
CL.6
Code List
Which types of assistance were required? (select all that apply)
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.4
Code List
If the Brief Pain Inventory 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))
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)
Item
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
text
CL.7
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))
Item Group
Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
Item Group
Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
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