ID

2488

Description

Southwest Oncology Group Quality of Life Cover Sheet Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF40B1-65D3-2947-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF40B1-65D3-2947-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer null Quality of Life - Southwest Oncology Group Quality of Life Cover Sheet - 2037591v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group Quality of Life Cover Sheet
    1. No Instruction available.
Unnamed 1
Description

Unnamed 1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Assessment
Description

Assessment

Data type

text

Patient Initials (L, F M)
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
Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Unnamed 2
Description

Unnamed 2

Amended Data
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed 3
Description

Unnamed 3

Was the Medical Conditions Questionnaire completed (Prestudy Only)?
Description

WastheMedicalConditionsQuestionnairecompleted(PrestudyOnly)?

Data type

text

Was the FACT-L TOI completed?
Description

WastheFACT-LTOIcompleted?

Data type

text

Date
Description

Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Date
Description

Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
If completed, in general, did the patient require assistance?
Description

Ifcompleted,ingeneral,didthepatientrequireassistance?

Data type

text

If Yes, describe
Description

IfYes,describe

Data type

text

If completed, questionnaire(s) administered
Description

Ifcompleted,questionnaire(s)administered

Data type

text

Other (please specify)
Description

Other(pleasespecify)

Data type

text

If Not Completed, please give reason (select one)
Description

PatientIncompleteQuestionnaireReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Unnamed 4
Description

Unnamed 4

By
Description

By

Data type

text

Phone
Description

Phone

Data type

text

Notes
Description

Notes

Notes
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group Quality Of Life Cover Sheet
Description

Ccrr Module For Southwest Oncology Group Quality Of Life Cover Sheet

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Southwest Oncology Group Quality of Life Cover Sheet
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Item
Assessment
text
CL.1
Code List
Assessment
CL Item
Prestudy (Prestudy)
CL Item
Week 7 (Week 7)
CL Item
Week 13 (Week 13)
PatientInitialsName
Item
Patient Initials (L, F M)
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)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
RegisteredInvestigator
Item
Physician
text
Item Group
Unnamed 2
Item
Amended Data
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.2
Code List
Amended Data
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed 3
Item
Was the Medical Conditions Questionnaire completed (Prestudy Only)?
text
CL.3
Code List
Was the Medical Conditions Questionnaire completed (Prestudy Only)?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Was the FACT-L TOI completed?
text
CL.4
Code List
Was the FACT-L TOI completed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
If completed, in general, did the patient require assistance?
text
CL.5
Code List
If completed, in general, did the patient require assistance?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IfYes,describe
Item
If Yes, describe
text
Item
If completed, questionnaire(s) administered
text
CL.6
Code List
If completed, questionnaire(s) administered
CL Item
In The Clinic (In the clinic)
CL Item
By Telephone (By telephone)
CL Item
Other (please Specify) (Other (please specify))
Other(pleasespecify)
Item
Other (please specify)
text
Item
If Not Completed, please give reason (select one)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
CL.7
Code List
If Not Completed, please give reason (select one)
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Not Illness Related (Not illness related)
CL Item
Institution Error (Institution error)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item Group
Unnamed 4
By
Item
By
text
Phone
Item
Phone
text
Item Group
Notes
Comments
Item
Notes
text
Item Group
Ccrr Module For Southwest Oncology Group Quality Of Life Cover Sheet
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