INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 Formulär

StudyEvent: RTOG 1016 HP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer The Health Utility Measurement Euro (EQ-5D)
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

Unnamed Module 1

Beskrivning

Unnamed Module 1

RTOG Study No.

Beskrivning

Protocol ID RTOG

Datatyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C3274381

NCI Thesaurus ObjectClass: C25320

UMLS CUI-2: C1514695

NCI Thesaurus Property: C19778

NCI Thesaurus Property-2: C25364

Case #

Beskrivning

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Datatyp

text

Alias

NCI Thesaurus ObjectClass: C16960

UMLS 2011AA ObjectClass: C0030705

NCI Thesaurus ObjectClass-2: C19778

UMLS 2011AA ObjectClass-2: C1514695

NCI Thesaurus Property: C25364

UMLS 2011AA Property: C0600091

NCI Thesaurus Property-2: C49152

UMLS 2011AA Property-2: C1706256

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

Institution Name

Beskrivning

Institution Name

Datatyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C1301943

NCI Thesaurus ObjectClass: C21541

NCI Thesaurus ValueDomain-2: C21541

NCI Thesaurus Property: C25364

Institution No.

Beskrivning

Institution Number

Datatyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C1301943

NCI Thesaurus ObjectClass: C21541

UMLS CUI-2: C0805701

NCI Thesaurus Property: C25364

Patient Initials

Beskrivning

Patient Initials

Datatyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C2986440

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25536

RTOG Patient ID

Beskrivning

Trial subject ID RTOG

Datatyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS CUI-1: C2348585

NCI Thesaurus ObjectClass: C16960

UMLS CUI-2: C1514695

NCI Thesaurus Property: C19778

NCI Thesaurus Property-2: C25364

Amended data

Beskrivning

Data amended

Datatyp

boolean

Alias

NCI Thesaurus ValueDomain: C38148

UMLS CUI-1: C0680532

NCI Thesaurus ObjectClass: C25474

NCI Thesaurus Property: C25416

Yes

Unamed Module 2

Beskrivning

Unamed Module 2

EQ-5D Health Questionnaire

Beskrivning

EQ-5D Health Questionnaire

Datatyp

text

Alias

UMLS CUI [1]: C2733251

Unnamed Module 3

Beskrivning

Unnamed Module 3

Your own health state today

Beskrivning

PatientHealthScore

Datatyp

float

Alias

NCI Thesaurus ObjectClass: C16960

UMLS 2011AA ObjectClass: C0030705

NCI Thesaurus Property: C25178

UMLS 2011AA Property: C0018684

NCI Thesaurus ValueDomain: C25338

UMLS 2011AA ValueDomain: C0449820

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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 Formulär

StudyEvent: RTOG 1016 HP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer The Health Utility Measurement Euro (EQ-5D)
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

Header Module

Item Group

Unnamed Module 1

Protocol ID RTOG

Item

RTOG Study No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Item

Case #

text

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)

Institution Name

Item

Institution Name

text

C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)

Institution Number

Item

Institution No.

text

C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)

Patient Initials

Item

Patient Initials

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Trial subject ID RTOG

Item

RTOG Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Data amended

Item

Amended data

boolean

C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)

EQ-5D Health Questionnaire

Item Group

Unamed Module 2

EQ-5D Health Questionnaire

Item

EQ-5D Health Questionnaire

text

C2733251 (UMLS CUI [1])

Health State

Item Group

Unnamed Module 3

PatientHealthScore

Item

Your own health state today

float

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)

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