ID

23849

Description

Follow-up contact as identified in the protocol. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFF3AFA-BEEC-470F-E040-BB89AD43497B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ACFF3AFA-BEEC-470F-E040-BB89AD43497B

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/15/17 7/15/17 - Martin Dugas
Uploaded on

July 15, 2017

DOI

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License

Creative Commons BY-NC 3.0
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CCR 2011 Template

English

No Instruction available.

1 forms  
  1. StudyEvent: Follow-up
    1. No Instruction available.
Follow-up
Description

Follow-up

Alias
UMLS CUI-1
C1522577
Date form originally completed
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
UMLS CUI [1]
C1549507
Last Contact Date
Description

Last Contact Date

Data type

date

Alias
NCI Thesaurus Property
C25164
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C47954
NCI Thesaurus ObjectClass
C25551
UMLS CUI [1]
C0585085
Type of Contact
Description

(Select how the information was obtained:)

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25461
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0332307
Received Treatment Since Last Contact?
Description

(Note: When answering 'Yes' and the patient has died during the follow-up period, only the Date of Death, entered on the Survival case report form, is sent to CTMS.)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25461
NCI Thesaurus ObjectClass
C25551
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0205314
Patient Status
Description

(Select one of the options below that indicates the patient's last known status. If the patient has died, enter the date in the Date of Death field.)

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25162
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25688
UMLS CUI [1,1]
C0805701
UMLS CUI [1,2]
C0030705
UMLS CUI [1,3]
C0449438
Explain 'Unknown' Patient Status
Description

(If Patient Status is unknown, enter some explanation here. Include what attempts were made and how many attempts where made in order to obtain the patient's status i.e.: no response to 5 messages left.)

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25688
NCI Thesaurus ValueDomain
C45255
NCI Thesaurus ValueDomain
C42614
NCI Thesaurus ValueDomain
C68805
UMLS CUI [1,1]
C1148433
UMLS CUI [1,2]
C0439673
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Follow-up
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Follow-up
C1522577 (UMLS CUI-1)
Form Completion Date
Item
Date form originally completed
date
C25164 (NCI Thesaurus ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C1549507 (UMLS CUI [1])
Last Contact Date
Item
Last Contact Date
date
C25164 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C47954 (NCI Thesaurus ObjectClass)
C25551 (NCI Thesaurus ObjectClass)
C0585085 (UMLS CUI [1])
Item
Type of Contact
integer
C25284 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25461 (NCI Thesaurus Property)
C1512346 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
CL.1
Code List
Type of Contact
CL Item
Telephone Contact With Patient/participant (1)
CL Item
Telephone contact with Patient/Participant Family (2)
CL Item
Telephone contact with Patient/Participant Local Physician (3)
CL Item
Social Security Death Index (SSDI (4)
CL Item
Clinic Appointment (5)
CL Item
Mail contact with Patient/Participant (6)
CL Item
Email contact with Patient/Participant (7)
Treatment Since Last Contact
Item
Received Treatment Since Last Contact?
boolean
C25180 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25461 (NCI Thesaurus Property)
C25551 (NCI Thesaurus ObjectClass)
C0087111 (UMLS CUI [1,1])
C0205314 (UMLS CUI [1,2])
Item
Patient Status
integer
C25162 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus Property)
C0805701 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C0449438 (UMLS CUI [1,3])
CL.3
Code List
Patient Status
CL Item
Alive With Disease (1)
C2584946 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
CL Item
Alive With No Evidence Of Disease (2)
C2584946 (UMLS CUI-1)
C0497153 (UMLS CUI-2)
CL Item
Alive Disease Status Unknown (3)
C2584946 (UMLS CUI-1)
C3898906 (UMLS CUI-2)
CL Item
Unknown (4)
C17998 (NCI Thesaurus)
C0439673 (UMLS CUI-1)
CL Item
Died (5)
C0011065 (UMLS CUI-1)
Survival Status, unknown
Item
Explain 'Unknown' Patient Status
text
C16960 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus Property)
C45255 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C68805 (NCI Thesaurus ValueDomain)
C1148433 (UMLS CUI [1,1])
C0439673 (UMLS CUI [1,2])
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