ID

11470

Description

NCT00087178 NSABP Protocol B-36 Missing Data Form for Quality of Life Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C8CBE2C5-1EEF-3461-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C8CBE2C5-1EEF-3461-E034-0003BA12F5E7

Keywords

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/5/15 7/5/15 -
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July 5, 2015

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License

Creative Commons BY-NC 3.0 Legacy

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    NCT00087178 NSABP Protocol B-36 Missing Data Form for Quality of Life Questionnaire

    Submit this form to the NSABP Biostatistical Center whenever a protocol-scheduled Quality of Life Questionnaire (QOL) or Menstrual History Form (MH-F) is not filled out by the patient and the assessment cannot be obtained by phone or mail.

    Header
    Description

    Header

    Patient Initials (Last, First Middle)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    NSABP Patient ID
    Description

    Patient ID NSABP

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1513905
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C15818
    Institution Name
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Affiliate Name
    Description

    Affiliate Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-1
    C1510825
    NCI Thesaurus ObjectClass-2
    C25413
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Person Completing Form (First Name)
    Description

    Person Completing Form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Person Completing Form (First Name)
    Description

    Person Completing Form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Person Completing Form (Phone)
    Description

    Person Completing Form Phone

    Data type

    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
    Today's Date (Month Day Year)
    Description

    Today'sDate

    Data type

    text

    Are data amended?
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Missing Data Form for Quality of Life Questionnaire
    Description

    Missing Data Form for Quality of Life Questionnaire

    Time Point for this Form (mark one)
    Description

    AbsentQualityofLifeAssessmentPeriodType

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus ObjectClass-2
    C20989
    UMLS 2011AA ObjectClass-2
    C0031809
    NCI Thesaurus ObjectClass-3
    C48190
    UMLS 2011AA ObjectClass-3
    C0332197
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Form(s) missing (mark one or both)
    Description

    CaseReportFormAbsent

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    Description

    QualityOfLifeNotAssessedReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    Description

    QualityOfLifeNotAssessedReason

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    Other (specify)
    Description

    QualityOfLifeNotAssessedSpecifiedReason

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    Other (specify)
    Description

    QualityOfLifeNotAssessedSpecifiedReason

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    Comments
    Description

    Comments

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire
    Description

    Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire

    Similar models

    Submit this form to the NSABP Biostatistical Center whenever a protocol-scheduled Quality of Life Questionnaire (QOL) or Menstrual History Form (MH-F) is not filled out by the patient and the assessment cannot be obtained by phone or mail.

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    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)
    Patient ID NSABP
    Item
    NSABP Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1513905 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C15818 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Affiliate Name
    Item
    Affiliate Name
    text
    C21541 (NCI Thesaurus ObjectClass)
    C1510825 (UMLS CUI-1)
    C25413 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Person Completing Form
    Item
    Person Completing Form (First Name)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Person Completing Form
    Item
    Person Completing Form (First Name)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Person Completing Form Phone
    Item
    Person Completing Form (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)
    Today'sDate
    Item
    Today's Date (Month Day Year)
    text
    Data amended
    Item
    Are data amended?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Missing Data Form for Quality of Life Questionnaire
    Item
    Time Point for this Form (mark one)
    text
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus ObjectClass-2)
    C0031809 (UMLS 2011AA ObjectClass-2)
    C48190 (NCI Thesaurus ObjectClass-3)
    C0332197 (UMLS 2011AA ObjectClass-3)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Time Point for this Form (mark one)
    CL Item
    6 month follow-up (6 month follow-up)
    CL Item
    Day 1 of Cycle #4 (Day 1 of Cycle #4)
    CL Item
    12 month follow-up (12 month follow-up)
    CL Item
    18 month follow-up (18 month follow-up)
    CL Item
    24 month follow-up (24 month follow-up)
    CL Item
    30 month follow-up (30 month follow-up)
    CL Item
    36 month follow-up (36 month follow-up)
    CL Item
    42 month follow-up (42 month follow-up)
    Item
    Form(s) missing (mark one or both)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    Code List
    Form(s) missing (mark one or both)
    CL Item
    QOL (QOL)
    CL Item
    MH-F (MH-F)
    Item
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    Code List
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    CL Item
    Staff oversight or understaffing (Staff oversight or understaffing)
    CL Item
    Staff was unable to contact patient by phone (Staff was unable to contact patient by phone)
    CL Item
    Patient refused to complete questionnaire (Patient refused to complete questionnaire)
    CL Item
    Questionnaire was mailed to patient but she did not return it (Questionnaire was mailed to patient but she did not return it)
    CL Item
    Other (specify) (Other (specify))
    Item
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    Code List
    Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
    CL Item
    Staff oversight or understaffing (Staff oversight or understaffing)
    CL Item
    Staff was unable to contact patient by phone (Staff was unable to contact patient by phone)
    CL Item
    Patient refused to complete questionnaire (Patient refused to complete questionnaire)
    CL Item
    Questionnaire was mailed to patient but she did not return it (Questionnaire was mailed to patient but she did not return it)
    CL Item
    Other (specify) (Other (specify))
    QualityOfLifeNotAssessedSpecifiedReason
    Item
    Other (specify)
    text
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    QualityOfLifeNotAssessedSpecifiedReason
    Item
    Other (specify)
    text
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Item Group
    Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire

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