ID

2178

Beschrijving

Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet Radiation Therapy and Stereotactic Radiosurgery With or Without Temozolomide or Erlotinib in Treating Patients With Brain Metastases Secondary to Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA3BB6-3594-636D-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA3BB6-3594-636D-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00096265 Quality of Life - Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet - 2277042v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet
    1. No Instruction available.
Header
Beschrijving

Header

[RTOG Study No.]
Beschrijving

ProtocolRTOGIdentifierNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

InstitutionName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Beschrijving

InstitutionIdentifierNumber

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participant's Name
Beschrijving

PatientName

Datatype

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
Participant's I.D. No.
Beschrijving

PatientCoordinatingIdentifierNumber

Datatype

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
Module 1
Beschrijving

Module 1

If this is a revised or corrected form, indicate by checking box.
Beschrijving

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Datatype

text

Module 2
Beschrijving

Module 2

Calendar Due Date
Beschrijving

CalenderDueDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C19459
UMLS 2011AA ObjectClass
C1516147
NCI Thesaurus Property
C45263
UMLS 2011AA Property
C0678226
Was questionnaire completed?
Beschrijving

QualityofLifeCompleteAssessmentInd-2

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Date Questionnaire Completed
Beschrijving

QualityofLifeCompleteAssessmentDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Other reason, specify
Beschrijving

QOLNotAdministeredSpecify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Type of Quality of Life Form
Beschrijving

TypeofQualityofLifeForm

Datatype

text

Time point of assessment of protocol treatment
Beschrijving

Timepointofassessmentofprotocoltreatment

Datatype

text

Other, specify
Beschrijving

Other,specify

Datatype

text

Did the patient require assistance in completing the radiotherapy questionnaire?
Beschrijving

Didthepatientrequireassistanceincompletingtheradiotherapyquestionnaire?

Datatype

text

Who
Beschrijving

Who

Datatype

text

Reason
Beschrijving

Reason

Datatype

text

Reason Questionnaire Was Not Completed
Beschrijving

ReasonQuestionnaireWasNotCompleted

Datatype

text

Patient refused, specify reason for refusal
Beschrijving

Patientrefused,specifyreasonforrefusal

Datatype

text

Module 3
Beschrijving

Module 3

Comments
Beschrijving

ResearchCommentsText

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Signature of person completing cover page
Beschrijving

ResponsiblePersonSignatureText

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Date
Beschrijving

ResponsiblePersonSignatureDate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
Item
[RTOG Study No.]
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL.1
Code List
[RTOG Study No.]
CL Item
RTOG Study 0320 (RTOG Study 0320)
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientName
Item
Participant's Name
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)
PatientCoordinatingIdentifierNumber
Item
Participant's I.D. No.
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)
Item Group
Module 1
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box.
text
Item Group
Module 2
CalenderDueDate
Item
Calendar Due Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19459 (NCI Thesaurus ObjectClass)
C1516147 (UMLS 2011AA ObjectClass)
C45263 (NCI Thesaurus Property)
C0678226 (UMLS 2011AA Property)
Item
Was questionnaire completed?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
CL.3
Code List
Was questionnaire completed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
QOLNotAdministeredSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item
Type of Quality of Life Form
text
CL.2
Code List
Type of Quality of Life Form
CL Item
Eq5d (EQ5D)
CL Item
Fact-g (Fact-G)
CL Item
Fact Subscale (Fact Subscale)
Item
Time point of assessment of protocol treatment
text
CL.4
Code List
Time point of assessment of protocol treatment
CL Item
Baseline/pretreatment (Pretreatment)
CL Item
3 Month Follow-up (Three (3) month follow-up)
CL Item
6 Month Follow-up (Six (6) month follow-up)
CL Item
9 Month Follow-up (Nine (9) month follow-up)
CL Item
12 Month Follow-up (Twelve (12) month follow-up)
CL Item
18 Month Follow-up (Eighteen (18) month follow-up)
CL Item
24 Month Follow-up (Twenty-four (24) month follow-up)
CL Item
Other, Specify (Other)
Other,specify
Item
Other, specify
text
Item
Did the patient require assistance in completing the radiotherapy questionnaire?
text
CL.5
Code List
Did the patient require assistance in completing the radiotherapy questionnaire?
CL Item
No (No)
CL Item
Yes (Yes)
Who
Item
Who
text
Reason
Item
Reason
text
Item
Reason Questionnaire Was Not Completed
text
CL.6
Code List
Reason Questionnaire Was Not Completed
CL Item
Not Applicable (Not applicable)
CL Item
Patient Too Ill (Patient was too ill)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Institution Error (Questionnaire not completed due to institutional error)
CL Item
Institution Not Participating In Qol (Institution not participating in QOL)
CL Item
Patient Refused (Patient refused)
CL Item
Other Reason (Other reason)
CL Item
Unknown (Unknown)
Patientrefused,specifyreasonforrefusal
Item
Patient refused, specify reason for refusal
text
Item Group
Module 3
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureText
Item
Signature of person completing cover page
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
ResponsiblePersonSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
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