ID

1787

Description

Sarcoma - Functional Evaluation Form for Extremity Primary Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E298AD03-E4A8-0934-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E298AD03-E4A8-0934-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Sarcoma - Functional Evaluation Form for Extremity Primary - 2290878v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Sarcoma - Functional Evaluation Form for Extremity Primary
    1. No Instruction available.
Crf Header
Description

Crf Header

Coordinating Group Protocol No.
Description

ProtocolCoordinatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Coordinating Group Code
Description

CoordinatingGroupIdentifierCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus ObjectClass
C25462
UMLS 2011AA ObjectClass
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Protocol Title
Description

ProtocolTitleName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C42774
UMLS 2011AA Property
C1705823
Patient Study ID
Description

PatientCoordinatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution/Affiliate
Description

CombinedInstitutionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Other Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Code
Description

ParticipatingGroupIdentifierCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Name (initials acceptable)
Description

PatientName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Sarcoma: Form Administration
Description

Sarcoma: Form Administration

Person Completing Form
Description

ResponsiblePersonName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended (If data are amended, please circle in red when using paper form)
Description

DataAmendedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Sarcoma: Functional Evaluation
Description

Sarcoma: Functional Evaluation

Function (Lower Limb Assessment)
Description

LowerLimbFunctionScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus ObjectClass
C25309
UMLS 2011AA ObjectClass
C0441994
NCI Metathesaurus ObjectClass
C0015385
Supports
Description

LowerLimbBracesType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25309
UMLS 2011AA ObjectClass
C0441994
NCI Metathesaurus ObjectClass
C0015385
NCI Metathesaurus Property
C0006086
Walking
Description

WalkingPatientAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus ObjectClass
C0080331
Gait
Description

PatientGaitAssessmentScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0016928
Pain
Description

LowerLimbPainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus ObjectClass
C25309
UMLS 2011AA ObjectClass
C0441994
NCI Metathesaurus ObjectClass
C0015385
Emotional Acceptance
Description

LowerLimbAssessmentEmotionalScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25309
UMLS 2011AA ObjectClass
C0441994
NCI Metathesaurus ObjectClass
C0015385
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C25495
Function (Upper Limb Assessment)
Description

UpperLimbFunctionScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus ObjectClass
C25355
UMLS 2011AA ObjectClass
C1282910
NCI Metathesaurus ObjectClass
C0015385
Hand Position
Description

PatientHandPositionScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C32712
UMLS 2011AA Property
C0018563
NCI Thesaurus Property
C25339
UMLS 2011AA Property
C0733755
Dexterity
Description

PatientEvaluationPhysicalDexterityFunctionScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Metathesaurus Property
C0237569
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
Lifting
Description

UpperLimbFunctionMovementScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25518
UMLS 2011AA Property
C0542341
NCI Thesaurus ObjectClass
C25355
UMLS 2011AA ObjectClass
C1282910
NCI Metathesaurus ObjectClass
C0015385
Pain
Description

UpperLimbPainScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus ObjectClass
C25355
UMLS 2011AA ObjectClass
C1282910
NCI Metathesaurus ObjectClass
C0015385
Emotional Acceptance
Description

UpperLimbAssessmentEmotionalScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C25355
UMLS 2011AA ObjectClass
C1282910
NCI Metathesaurus ObjectClass
C0015385
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C25495
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1 forms
  1. StudyEvent: Sarcoma - Functional Evaluation Form for Extremity Primary
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Crf Header
ProtocolCoordinatingIdentifierNumber
Item
Coordinating Group Protocol No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CoordinatingGroupIdentifierCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus ObjectClass)
C0700114 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolTitleName
Item
Protocol Title
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)
PatientCoordinatingIdentifierNumber
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
PatientParticipatingIdentifierNumber
Item
Other Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ParticipatingGroupIdentifierCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientName
Item
Patient Name (initials acceptable)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Sarcoma: Form Administration
ResponsiblePersonName
Item
Person Completing Form
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended (If data are amended, please circle in red when using paper form)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended (If data are amended, please circle in red when using paper form)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Sarcoma: Functional Evaluation
Item
Function (Lower Limb Assessment)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25309 (NCI Thesaurus ObjectClass)
C0441994 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
CL.2
Code List
Function (Lower Limb Assessment)
CL Item
No Restriction (No restriction)
CL Item
Recreational Restriction (Recreational restriction)
CL Item
Partial Disability (Partial disability)
CL Item
Total Disability (Total disability)
Item
Supports
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25309 (NCI Thesaurus ObjectClass)
C0441994 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
C0006086 (NCI Metathesaurus Property)
CL.3
Code List
Supports
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Brace (Brace)
CL Item
1 Cane Or Crutch (1 cane or crutch)
CL Item
2 Canes Or Crutches (2 canes or crutches)
Item
Walking
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0080331 (NCI Metathesaurus ObjectClass)
CL.4
Code List
Walking
CL Item
Unlimited (Unlimited)
CL Item
Limited (Limited)
CL110648 (NCI Metathesaurus)
CL Item
Inside Only (Inside only)
CL Item
Not Independently (Not independently)
Item
Gait
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0016928 (NCI Metathesaurus Property)
CL.5
Code List
Gait
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Minor Cosmetic (Minor cosmetic)
CL Item
Major Cosmetic, Minor Handicap (Major cosmetic, minor handicap)
CL Item
Major Handicap (Major handicap)
Item
Pain
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25309 (NCI Thesaurus ObjectClass)
C0441994 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
CL.6
Code List
Pain
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Modest (Modest)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
Emotional Acceptance
text
C25309 (NCI Thesaurus ObjectClass)
C0441994 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25495 (NCI Thesaurus ValueDomain)
CL.7
Code List
Emotional Acceptance
CL Item
Enthused (Enthused)
CL Item
Likes (Likes)
CL Item
Satisfied (Satisfied)
CL Item
Intermediate (Intermediate)
C0205103 (NCI Metathesaurus)
CL Item
Accepts (Accepts)
CL Item
Dislikes (Dislikes)
Item
Function (Upper Limb Assessment)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25355 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
CL.8
Code List
Function (Upper Limb Assessment)
CL Item
No Restriction (No restriction)
CL Item
Recreational Restriction (Recreational restriction)
CL Item
Partial Disability (Partial disability)
CL Item
Total Disability (Total disability)
Item
Hand Position
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C32712 (NCI Thesaurus Property)
C0018563 (UMLS 2011AA Property)
C25339 (NCI Thesaurus Property)
C0733755 (UMLS 2011AA Property)
CL.9
Code List
Hand Position
CL Item
No Limitations (No limitations)
CL Item
Not Above Shoulder Or No Pro/supination (Not above shoulder or no pro/supination)
CL Item
Not Above Waist (Not above waist)
CL Item
Flail (Flail)
Item
Dexterity
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C0237569 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.10
Code List
Dexterity
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Loss Of Fine Movement (Loss of fine movement)
CL Item
Cannot Pinch (Cannot pinch)
CL Item
Cannot Grasp (Cannot grasp)
Item
Lifting
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
C25355 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
CL.11
Code List
Lifting
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Limited (Limited)
CL110648 (NCI Metathesaurus)
CL Item
Helping Capacity Only (Helping capacity only)
CL Item
Cannot Be Used To Help (Cannot be used to help)
Item
Pain
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25355 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
CL.12
Code List
Pain
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Modest (Modest)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
Emotional Acceptance
text
C25355 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C0015385 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25495 (NCI Thesaurus ValueDomain)
CL.13
Code List
Emotional Acceptance
CL Item
Enthused (Enthused)
CL Item
Likes (Likes)
CL Item
Satisfied (Satisfied)
CL Item
Intermediate (Intermediate)
C0205103 (NCI Metathesaurus)
CL Item
Accepts (Accepts)
CL Item
Dislikes (Dislikes)
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