ID

2239

Descrizione

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

collegamento

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

Keywords

versioni (3)
  1. 19/09/12 19/09/12 -
  2. 28/05/15 28/05/15 -
  3. 03/06/15 03/06/15 -
Caricato su

19 settembre 2012

DOI

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Licenza

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

Inglese

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

1 moduli  
  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
Descrizione

Unnamed 1

Case #
Descrizione

Case#

Tipo di dati

text

Institution
Descrizione

InstitutionName

Tipo di dati

text

Institution No.
Descrizione

InstitutionNo.

Tipo di dati

text

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

Patient'sName

Tipo di dati

text

Patient's I.D. No.
Descrizione

Patient'sI.D.No.

Tipo di dati

text

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

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Tipo di dati

text

Unnamed 2
Descrizione

Unnamed 2

Calender Due Date
Descrizione

CalenderDueDate

Tipo di dati

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
Descrizione

Dateofexamination

Tipo di dati

text

Date of 1st protocol Rx
Descrizione

FirstTreatmentStartDate

Tipo di dati

date

What is the year
Descrizione

Whatistheyear

Tipo di dati

text

What is the season
Descrizione

Whatistheseason

Tipo di dati

text

What is the date
Descrizione

Whatisthedate

Tipo di dati

text

What is the day
Descrizione

Whatistheday

Tipo di dati

text

What is the month
Descrizione

Whatisthemonth

Tipo di dati

text

What is the, Score
Descrizione

Whatisthe,Score

Tipo di dati

text

Where are we, state
Descrizione

Wherearewe,state

Tipo di dati

text

Where are we, country
Descrizione

Wherearewe,country

Tipo di dati

text

Where are we, town
Descrizione

Wherearewe,town

Tipo di dati

text

Where are we, hospital
Descrizione

Wherearewe,hospital

Tipo di dati

text

Where are we, floor
Descrizione

Wherearewe,floor

Tipo di dati

text

Where are we, Score
Descrizione

Wherearewe,Score

Tipo di dati

text

Registration Score
Descrizione

RegistrationScore

Tipo di dati

text

Attention and Calculation Score
Descrizione

AttentionandCalculationScore

Tipo di dati

text

Recall Score (Language)
Descrizione

RecallScore

Tipo di dati

text

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

Pointtothefollowingobjectsandhavepatientnameeach:apencilandawatch

Tipo di dati

text

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

Havethepatientrepeatthefollowing:"Noifs,andsorbuts"

Tipo di dati

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."
Descrizione

Havethepatientfollowa3stepcommand:"Takeapaperinyourrighthand,folditinhalf,andputitonthefloor."

Tipo di dati

text

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

Showthepatientthestatement"Closeyoureyesandhimreadandobeywhatitsays.

Tipo di dati

text

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

Havethepatientwriteasentencewithasubjectandaverb

Tipo di dati

text

Have the patient copy the figure
Descrizione

Havethepatientcopythefigure

Tipo di dati

text

MMSE Total Score
Descrizione

MMSETotalScore

Tipo di dati

text

Assess level of consciousness along a continuum
Descrizione

Assesslevelofconsciousnessalongacontinuum

Tipo di dati

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.
Descrizione

Ifanevaluationisnotdone,providethetimepointmissedandthereason.Ifnoneofthetestsaredone,providethereason.

Tipo di dati

text

Name/signature of person performing exam
Descrizione

Name/signatureofpersonperformingexam

Tipo di dati

text

Date
Descrizione

Date

Tipo di dati

date

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

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 moduli
  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
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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