ID

2239

Description

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A5D1AB4A-E01B-3595-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A5D1AB4A-E01B-3595-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00048997 Quality of Life - Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE - 2045704v3.0

English

Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.

1 forms  
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE
    1. Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.
Unnamed 1
Description

Unnamed 1

Case #
Description

Case#

Data type

text

Institution
Description

InstitutionName

Data type

text

Institution No.
Description

InstitutionNo.

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient's Name
Description

Patient'sName

Data type

text

Patient's I.D. No.
Description

Patient'sI.D.No.

Data type

text

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

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Data type

text

Unnamed 2
Description

Unnamed 2

Calender Due Date
Description

CalenderDueDate

Data type

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
Date of examination
Description

Dateofexamination

Data type

text

Date of 1st protocol Rx
Description

FirstTreatmentStartDate

Data type

date

What is the year
Description

Whatistheyear

Data type

text

What is the season
Description

Whatistheseason

Data type

text

What is the date
Description

Whatisthedate

Data type

text

What is the day
Description

Whatistheday

Data type

text

What is the month
Description

Whatisthemonth

Data type

text

What is the, Score
Description

Whatisthe,Score

Data type

text

Where are we, state
Description

Wherearewe,state

Data type

text

Where are we, country
Description

Wherearewe,country

Data type

text

Where are we, town
Description

Wherearewe,town

Data type

text

Where are we, hospital
Description

Wherearewe,hospital

Data type

text

Where are we, floor
Description

Wherearewe,floor

Data type

text

Where are we, Score
Description

Wherearewe,Score

Data type

text

Registration Score
Description

RegistrationScore

Data type

text

Attention and Calculation Score
Description

AttentionandCalculationScore

Data type

text

Recall Score (Language)
Description

RecallScore

Data type

text

Point to the following objects and have patient name each: a pencil and a watch
Description

Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

Data type

text

Have the patient repeat the following: "No ifs, ands or buts"
Description

Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

Data type

text

Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
Description

Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

Data type

text

Show the patient the statement "Close your eyes and him read and obey what it says.
Description

Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

Data type

text

Have the patient write a sentence with a subject and a verb
Description

Havethepatientwriteasentencewithasubjectandaverb

Data type

text

Have the patient copy the figure
Description

Havethepatientcopythefigure

Data type

text

MMSE Total Score
Description

MMSETotalScore

Data type

text

Assess level of consciousness along a continuum
Description

Assesslevelofconsciousnessalongacontinuum

Data type

text

If an evaluation is not done, provide the time point missed and the reason. If none of the tests are done, provide the reason.
Description

Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

Data type

text

Name/signature of person performing exam
Description

Name/signatureofpersonperformingexam

Data type

text

Date
Description

Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse
Description

Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse

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Similar models

Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.

1 forms
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT MMSE
    1. Instructions: To be completed by nurse, data manager or physician. All dates are mm/dd/yy.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 1
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
Patient'sI.D.No.
Item
Patient's I.D. No.
text
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box.
text
Item Group
Unnamed 2
CalenderDueDate
Item
Calender 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)
Dateofexamination
Item
Date of examination
text
FirstTreatmentStartDate
Item
Date of 1st protocol Rx
date
Whatistheyear
Item
What is the year
text
Whatistheseason
Item
What is the season
text
Whatisthedate
Item
What is the date
text
Whatistheday
Item
What is the day
text
Whatisthemonth
Item
What is the month
text
Item
What is the, Score
text
CL.1
Code List
What is the, Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Wherearewe,state
Item
Where are we, state
text
Wherearewe,country
Item
Where are we, country
text
Wherearewe,town
Item
Where are we, town
text
Wherearewe,hospital
Item
Where are we, hospital
text
Wherearewe,floor
Item
Where are we, floor
text
Item
Where are we, Score
text
CL.2
Code List
Where are we, Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Registration Score
text
CL.3
Code List
Registration Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Attention and Calculation Score
text
CL.4
Code List
Attention and Calculation Score
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Recall Score (Language)
text
CL.5
Code List
Recall Score (Language)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Point to the following objects and have patient name each: a pencil and a watch
text
CL.6
Code List
Point to the following objects and have patient name each: a pencil and a watch
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
Item
Have the patient repeat the following: "No ifs, ands or buts"
text
CL.7
Code List
Have the patient repeat the following: "No ifs, ands or buts"
CL Item
1 (1)
Item
Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
text
CL.8
Code List
Have the patient follow a 3 step command: "Take a paper in your right hand, fold it in half, and put it on the floor."
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
Show the patient the statement "Close your eyes and him read and obey what it says.
text
CL.9
Code List
Show the patient the statement "Close your eyes and him read and obey what it says.
CL Item
1 (1)
Item
Have the patient write a sentence with a subject and a verb
text
CL.10
Code List
Have the patient write a sentence with a subject and a verb
CL Item
1 (1)
Item
Have the patient copy the figure
text
CL.11
Code List
Have the patient copy the figure
CL Item
1 (1)
MMSETotalScore
Item
MMSE Total Score
text
Item
Assess level of consciousness along a continuum
text
CL.12
Code List
Assess level of consciousness along a continuum
CL Item
Alert (alert)
C64358 (NCI Thesaurus)
C0718338 (UMLS 2011AA)
CL Item
Drowsy (drowsy)
CL Item
Stupor (stupor)
CL Item
Coma (coma)
C34497 (NCI Thesaurus)
C0009421 (UMLS 2011AA)
Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.
Item
If an evaluation is not done, provide the time point missed and the reason. If none of the tests are done, provide the reason.
text
Name/signatureofpersonperformingexam
Item
Name/signature of person performing exam
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Radiation Therapy Oncology Group Phase Iii Lung Prophylactic Cranial Rt Mmse
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