ID

2313

Description

E1609 Assessment Compliance Form Ipilimumab or High-Dose Interferon Alfa-2b in Treating Patients With High-Risk Stage III or Stage IV Melanoma That Has Been Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=97E7C12F-E701-FFC2-E040-BB89AD43160A

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=97E7C12F-E701-FFC2-E040-BB89AD43160A

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 6/8/15 6/8/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) NCT01274338 Quality of Life - E1609 Assessment Compliance Form - 3172169v1.0

English

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

1 forms  
Unnamed1
Description

Unnamed1

ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
DCI Name
Description

CollectedDataFormName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
Registration Step
Description

RegistrationStepNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25646
UMLS 2011AA ObjectClass
C1514821
NCI Thesaurus Property
C16154
UMLS 2011AA Property
C1704379
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Unnamed2
Description

Unnamed2

Patient Initials (Last, First)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Participating Group Protocol Number
Description

ProtocolParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
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
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Participating Group 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
Unnamed3
Description

Unnamed3

Please mark an 'X' if data have been amended.
Description

DataAmendedText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Date data amended
Description

DataAmendedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
NCI Thesaurus ValueDomain
C25367
Unnamed4
Description

Unnamed4

On Treatment Report Period
Description

TreatmentEvaluationPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C15368
Unnamed4
Description

Unnamed4

Off Treatment Report Period
Description

PersonOff-TreatmentTimePeriodType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25601
UMLS 2011AA Property
C1518544
NCI Thesaurus Property
C25207
UMLS 2011AA Property
C0040223
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Section I
Description

Section I

Assessment date (If not completed, enter date scheduled per E1609 protocol.)
Description

AssessmentPerformedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25367
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
Section Ii - E1a05 Qol Assessment Not Completed
Description

Section Ii - E1a05 Qol Assessment Not Completed

Was the Assessment Form completed? (E1609 QOL)
Description

AssessmentFormCompletedInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C25367
Section Ii - Assessments Not Completed
Description

Section Ii - Assessments Not Completed

Patient refusal
Description

Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C49161
UMLS 2011AA Property
C1705116
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Unable to accomodate disability or language needs
Description

Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C21007
UMLS 2011AA Property
C0231170
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify disability or language
Description

Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C21007
UMLS 2011AA Property
C0231170
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Patient did not show up in clinic/office
Description

Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify reason patient did not show up
Description

Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Staff unavailable
Description

Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25429
UMLS 2011AA Property
C0470187
NCI Metathesaurus Property
C0025106
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Patient not given form by staff
Description

Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Patient too ill
Description

Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Metathesaurus Property
C0221423
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Patient expired
Description

Quality-of-LifeAssessmentPatientDeathIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C28554
UMLS 2011AA Property
C0011065
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Assessment not required per protocol
Description

Quality-of-LifeAssessmentNotRequiredIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25652
UMLS 2011AA Property
C1514873
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify reason assessment is not required
Description

Quality-of-LifeAssessmentNotRequiredIncompleteSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25652
UMLS 2011AA Property
C1514873
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Staff thought patient too ill
Description

Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Metathesaurus Property
C0221423
NCI Metathesaurus Property
C0025106
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Other
Description

Quality-of-LifeAssessmentOtherIncompleteInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Specify other reason
Description

Quality-of-LifeAssessmentOtherIncompleteSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Section Iii Assessment Completed
Description

Section Iii Assessment Completed

Was Assessment self-administered?
Description

AssessmentSelf-AdministeredInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C25217
UMLS 2011AA ObjectClass
C1516048
NCI Thesaurus Property
C25670
UMLS 2011AA Property
C1519231
How Was The Patient Assisted
Description

How Was The Patient Assisted

Were the questions read aloud to patient
Description

Quality-of-LifeAssessmentSpeechAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C38025
UMLS 2011AA Property
C0037817
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Did the patient require clarification of questions or instructions
Description

Quality-of-LifeAssessmentDefinitionAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Metathesaurus Property
C0018896
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C42777
UMLS 2011AA Property
C1704788
Did the patient require other assistance
Description

Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25652
UMLS 2011AA Property
C1514873
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Were the forms completed independently by another person
Description

Quality-of-LifeAssessmentOtherPersonCompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25190
UMLS 2011AA Property
C0027361
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
What Was The Reason For Assistance
Description

What Was The Reason For Assistance

Did the patient have a language difficulty (questions needed to tbe translated)
Description

Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C16779
UMLS 2011AA Property
C0023008
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify language
Description

Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C16779
UMLS 2011AA Property
C0023008
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Did the patient have a literacy difficulty (patient could not read well enough)
Description

Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C49162
UMLS 2011AA Property
C0023864
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Was the patient disabled
Description

Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C21007
UMLS 2011AA Property
C0231170
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Specify disability
Description

Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C21007
UMLS 2011AA Property
C0231170
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Were the forms completed via a telephone interview
Description

Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Metathesaurus Property
C0018896
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus Property
C16751
UMLS 2011AA Property
C0021822
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Other
Description

Quality-of-LifeAssessmentOtherAssistanceInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Specify other reason
Description

Quality-of-LifeAssessmentOtherAssistanceSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Metathesaurus Property
C0018896
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
Description

Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?

Staff
Description

Quality-of-LifeAssessmentMedicalStaffCompleteInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Metathesaurus Property
C0025106
Family
Description

Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C41256
UMLS 2011AA Property
C0086282
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Friend
Description

Quality-of-LifeAssessmentPatientFriendsCompleteInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Metathesaurus Property
C0079382
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Other
Description

Quality-of-LifeAssessmentOtherCompleteInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Specify other person
Description

Quality-of-LifeAssessmentOtherCompleteSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C15584
UMLS 2011AA ObjectClass
C0281588
Comments
Description

Comments

Investigator Signature
Description

InvestigatorSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Investigator Signature Date
Description

InvestigatorSignatureDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
RegistrationStepNumber
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
Item Group
Unnamed2
PatientInitialsName
Item
Patient Initials (Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (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)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Participating Group 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)
Item Group
Unnamed3
DataAmendedText
Item
Please mark an 'X' if data have been amended.
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
DataAmendedDate
Item
Date data amended
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item Group
Unnamed4
Item
On Treatment Report Period
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
CL.1
Code List
On Treatment Report Period
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
Week 12 (Week 12)
CL Item
Week 24 (Week 24)
CL Item
Week 36 (Week 36)
CL Item
Week 48 (Week 48)
CL Item
Week 60 (Week 60)
CL Item
At Completion Of Treatment (At Completion of Treatment)
Item Group
Unnamed4
Item
Off Treatment Report Period
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property)
C0040223 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Off Treatment Report Period
CL Item
Qol 24 Weeks Follow-up (QOL 24 Weeks Follow-Up)
CL Item
Qol 48 Weeks Follow-up (QOL 48 Weeks Follow-Up)
Item Group
Section I
AssessmentPerformedDate
Item
Assessment date (If not completed, enter date scheduled per E1609 protocol.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
Item Group
Section Ii - E1a05 Qol Assessment Not Completed
Item
Was the Assessment Form completed? (E1609 QOL)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ObjectClass)
CL.3
Code List
Was the Assessment Form completed? (E1609 QOL)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Section Ii - Assessments Not Completed
Item
Patient refusal
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property)
C1705116 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.4
Code List
Patient refusal
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Unable to accomodate disability or language needs
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C21007 (NCI Thesaurus Property)
C0231170 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.5
Code List
Unable to accomodate disability or language needs
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify
Item
Specify disability or language
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C21007 (NCI Thesaurus Property)
C0231170 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Patient did not show up in clinic/office
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.6
Code List
Patient did not show up in clinic/office
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify
Item
Specify reason patient did not show up
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Staff unavailable
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25429 (NCI Thesaurus Property)
C0470187 (UMLS 2011AA Property)
C0025106 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.7
Code List
Staff unavailable
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Patient not given form by staff
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.8
Code List
Patient not given form by staff
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Patient too ill
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.9
Code List
Patient too ill
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Patient expired
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C28554 (NCI Thesaurus Property)
C0011065 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.10
Code List
Patient expired
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Assessment not required per protocol
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.11
Code List
Assessment not required per protocol
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentNotRequiredIncompleteSpecify
Item
Specify reason assessment is not required
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Staff thought patient too ill
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
C0025106 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.12
Code List
Staff thought patient too ill
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
CL.13
Code List
Other
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentOtherIncompleteSpecify
Item
Specify other reason
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
Item Group
Section Iii Assessment Completed
Item
Was Assessment self-administered?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25217 (NCI Thesaurus ObjectClass)
C1516048 (UMLS 2011AA ObjectClass)
C25670 (NCI Thesaurus Property)
C1519231 (UMLS 2011AA Property)
CL.14
Code List
Was Assessment self-administered?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
How Was The Patient Assisted
Item
Were the questions read aloud to patient
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0018896 (NCI Metathesaurus Property)
C38025 (NCI Thesaurus Property)
C0037817 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
CL.15
Code List
Were the questions read aloud to patient
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Did the patient require clarification of questions or instructions
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0018896 (NCI Metathesaurus Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C42777 (NCI Thesaurus Property)
C1704788 (UMLS 2011AA Property)
CL.16
Code List
Did the patient require clarification of questions or instructions
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Did the patient require other assistance
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.17
Code List
Did the patient require other assistance
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Were the forms completed independently by another person
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.18
Code List
Were the forms completed independently by another person
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
What Was The Reason For Assistance
Item
Did the patient have a language difficulty (questions needed to tbe translated)
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C16779 (NCI Thesaurus Property)
C0023008 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.19
Code List
Did the patient have a language difficulty (questions needed to tbe translated)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify
Item
Specify language
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C16779 (NCI Thesaurus Property)
C0023008 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Did the patient have a literacy difficulty (patient could not read well enough)
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C49162 (NCI Thesaurus Property)
C0023864 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.20
Code List
Did the patient have a literacy difficulty (patient could not read well enough)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Was the patient disabled
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C21007 (NCI Thesaurus Property)
C0231170 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.21
Code List
Was the patient disabled
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify
Item
Specify disability
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C21007 (NCI Thesaurus Property)
C0231170 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Were the forms completed via a telephone interview
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C0018896 (NCI Metathesaurus Property)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C16751 (NCI Thesaurus Property)
C0021822 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.22
Code List
Were the forms completed via a telephone interview
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
CL.23
Code List
Other
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentOtherAssistanceSpecify
Item
Specify other reason
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C0018896 (NCI Metathesaurus Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
Item Group
Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
Item
Staff
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C0025106 (NCI Metathesaurus Property)
CL.24
Code List
Staff
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Family
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C41256 (NCI Thesaurus Property)
C0086282 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.25
Code List
Family
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Friend
text
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C0079382 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.26
Code List
Friend
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Other
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
CL.27
Code List
Other
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Quality-of-LifeAssessmentOtherCompleteSpecify
Item
Specify other person
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C15584 (NCI Thesaurus ObjectClass)
C0281588 (UMLS 2011AA ObjectClass)
Item Group
Comments
InvestigatorSignatureText
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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