ID

1694

Description

Follow-up contact as identified in the protocol. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFF3AFA-BEEC-470F-E040-BB89AD43497B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFF3AFA-BEEC-470F-E040-BB89AD43497B

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/15/17 7/15/17 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0
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Follow-Up - Follow-up - 3277911v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Follow-up
    1. No Instruction available.
Follow-up
Description

Follow-up

Visit Date
Description

FormCompletionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Date of Last Contact (Enter the date the patient was last contacted.)
Description

LastContactDate

Data type

date

Alias
NCI Thesaurus Property
C25164
UMLS 2011AA Property
C0011008
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C47954
UMLS 2011AA ObjectClass
C1705415
NCI Thesaurus ObjectClass
C25551
UMLS 2011AA ObjectClass
C1517741
Type of Contact (Select how the information was obtained:)
Description

PatientContactTextType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25461
UMLS 2011AA Property
C0337611
Received Treatment Since Last Contact? (Note: When answering 'Yes' and the patient has died during the follow-up period, only the Date of Death, entered on the Survival case report form, is sent to CTMS.)
Description

TreatmentSinceLastContactIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25461
UMLS 2011AA Property
C0337611
NCI Thesaurus ObjectClass
C25551
UMLS 2011AA ObjectClass
C1517741
Patient Status (Select one of the options below that indicates the patient's last known status. If the patient has died, enter the date in the Date of Death field.)
Description

PatientSurvivalStatus

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25688
UMLS 2011AA Property
C0449438
Explain 'Unknown' Patient Status (If Patient Status is unknown, enter some explanation here. Include what attempts were made and how many attempts where made in order to obtain the patient's status i.e.: no response to 5 messages left.)
Description

SurvivalStatus,unknownexplanation

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25688
UMLS 2011AA Property
C0449438
NCI Thesaurus ValueDomain
C45255
UMLS 2011AA ValueDomain
C1708523
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus ValueDomain
C68805
UMLS 2011AA ValueDomain
C2350015
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Follow-up
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Follow-up
FormCompletionDate
Item
Visit Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
LastContactDate
Item
Date of Last Contact (Enter the date the patient was last contacted.)
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C47954 (NCI Thesaurus ObjectClass)
C1705415 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass)
C1517741 (UMLS 2011AA ObjectClass)
Item
Type of Contact (Select how the information was obtained:)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25461 (NCI Thesaurus Property)
C0337611 (UMLS 2011AA Property)
CL.1
Code List
Type of Contact (Select how the information was obtained:)
CL Item
Telephone Contact With Patient/participant (Telephone contact with Patient/Participant)
CL Item
Telephone Contact With Patient/participant Family (Telephone contact with Patient/Participant Family)
CL Item
Telephone Contact With Patient/participant Local Physician (Telephone contact with Patient/Participant Local Physician)
CL Item
Social Security Death Index (ssdi) (Social Security Death Index (SSDI))
CL Item
Clinic Appointment (Clinic Appointment)
CL Item
Mail Contact With Patient/participant (Mail contact with Patient/Participant)
CL Item
Email Contact With Patient/participant (Email contact with Patient/Participant)
Item
Received Treatment Since Last Contact? (Note: When answering 'Yes' and the patient has died during the follow-up period, only the Date of Death, entered on the Survival case report form, is sent to CTMS.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25461 (NCI Thesaurus Property)
C0337611 (UMLS 2011AA Property)
C25551 (NCI Thesaurus ObjectClass)
C1517741 (UMLS 2011AA ObjectClass)
CL.2
Code List
Received Treatment Since Last Contact? (Note: When answering 'Yes' and the patient has died during the follow-up period, only the Date of Death, entered on the Survival case report form, is sent to CTMS.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Patient Status (Select one of the options below that indicates the patient's last known status. If the patient has died, enter the date in the Date of Death field.)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus Property)
C0449438 (UMLS 2011AA Property)
CL.3
Code List
Patient Status (Select one of the options below that indicates the patient's last known status. If the patient has died, enter the date in the Date of Death field.)
CL Item
Alive With Disease (1)
CL Item
Alive With No Evidence Of Disease (2)
CL Item
Alive Disease Status Unknown (3)
CL Item
Unknown (4)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Died (5)
SurvivalStatus,unknownexplanation
Item
Explain 'Unknown' Patient Status (If Patient Status is unknown, enter some explanation here. Include what attempts were made and how many attempts where made in order to obtain the patient's status i.e.: no response to 5 messages left.)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus Property)
C0449438 (UMLS 2011AA Property)
C45255 (NCI Thesaurus ValueDomain)
C1708523 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C68805 (NCI Thesaurus ValueDomain)
C2350015 (UMLS 2011AA ValueDomain)
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