ID

2901

Description

RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form Higher-Dose Radiation Therapy or Standard Radiation Therapy in Treating Patients With Early-Stage Breast Cancer That Was Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D7B30AD-FF6E-0FB3-E040-BB89AD435271

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D7B30AD-FF6E-0FB3-E040-BB89AD435271

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 7/8/15 7/8/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT01349322 Quality of Life - RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form - 3194403v1.0

English

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms  
  1. StudyEvent: RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

ProtocolRTOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

InstitutionName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Description

InstitutionIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
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
RTOG Patient ID
Description

PatientRadiationTherapyOncologyGroupIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended
Description

DataAmendedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unamed Module 2
Description

Unamed Module 2

Time point
Description

AssessmentPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Treatment Start Date
Description

TreatmentBeginDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25431
UMLS 2011AA Property
C0439659
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25431
UMLS 2011AA ValueDomain
C0439659
Evaluation performed by
Description

PersonEvaluationSocialRoleType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C25199
UMLS 2011AA Property
C0035820
Date Questionnaire Completed (MM DD YYYY)
Description

QualityofLifeCompleteAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25367
Reason Questionnaire was not Completed
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
Patient refused for other reason, specify
Description

PatientRefuseIncompleteQuestionnaireSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus Property
C49161
UMLS 2011AA Property
C1705116
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Other reason, specify
Description

PatientIncompleteQuestionnaireOtherSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain
C17649
UMLS 2011AA ValueDomain
C0205394
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0034394
Signature
Description

ResponsiblePersonSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Date Form Completed
Description

FormCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C25367
Unnamed2
Description

Unnamed2

Please assess breast cosmesis at this time
Description

BreastReconstructionAssessmentSatus

Data type

text

Alias
NCI Thesaurus Property
C25367
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
Skin telangiectasia
Description

BreastReconstructionTelangiectasiaAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C28194
UMLS 2011AA Property
C0039446
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Skin atrophy
Description

BreastReconstructionAtrophyAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C79748
UMLS 2011AA Property
C0333641
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Scarring
Description

BreastReconstructionScarAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C34483
UMLS 2011AA Property
C2004491
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pigment change
Description

BreastReconstructionPigmentAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C747
UMLS 2011AA Property
C0031916
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Erythema
Description

BreastReconstructionErythemaAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C26901
UMLS 2011AA Property
C0041834
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Fat necrosis
Description

BreastReconstructionFatNecrosisAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C26772
UMLS 2011AA Property
C0015668
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Fibrosis
Description

BreastReconstructionFibrosisAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C3044
UMLS 2011AA Property
C0016059
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Retraction or contour defect
Description

BreastReconstructionDefectAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C43429
UMLS 2011AA Property
C1457869
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Volume loss
Description

BreastReconstructionLossAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C25559
UMLS 2011AA Property
C1517945
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other significant treatment effect
Description

BreastReconstructionOtherAssessmentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify
Description

BreastReconstructionOtherAssessmentSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass
C25351
UMLS 2011AA ObjectClass
C0524865
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Footer Module
Description

Footer Module

Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Date
Description

ResponsiblePersonSignatureDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Signature
Description

ResponsiblePersonSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
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This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms
  1. StudyEvent: RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials
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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Are data amended
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unamed Module 2
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.2
Code List
Time point
CL Item
Pretreatment (Pretreatment)
CL Item
1 Year Post Rt Completion (1 year post RT Completion)
CL Item
3 Years Post Rt Completion (3 years post RT Completion)
TreatmentBeginDate
Item
Treatment Start Date
date
C15368 (NCI Thesaurus ObjectClass)
C25431 (NCI Thesaurus Property)
C0439659 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
Item
Evaluation performed by
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25199 (NCI Thesaurus Property)
C0035820 (UMLS 2011AA Property)
CL.3
Code List
Evaluation performed by
CL Item
Surgeon (Surgeon)
C18071 (NCI Thesaurus)
C0582175 (UMLS 2011AA)
CL Item
Radiation Oncologist (Radiation Oncologist)
C17833 (NCI Thesaurus)
C1514693 (UMLS 2011AA)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
Item
Reason Questionnaire was not Completed
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
CL.4
Code List
Reason Questionnaire was not Completed
CL Item
Not Applicable, Questionnaire Was Completed (Not applicable, questionnaire was completed)
CL Item
Patient Refused Due To Illness (Patient refused due to illness)
CL Item
Patient Refused For Other Reason (Patient refused for other reason)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Institution Error (Institutional error)
CL Item
Patient Withdrew Consent Prior/after (Patient withdrew consent prior/after)
CL Item
Other Reason (Other reason)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PatientRefuseIncompleteQuestionnaireSpecify
Item
Patient refused for other reason, specify
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C49161 (NCI Thesaurus Property)
C1705116 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
PatientIncompleteQuestionnaireOtherSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain)
C0205394 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0034394 (NCI Metathesaurus Property)
ResponsiblePersonSignatureText
Item
Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
FormCompleteDate
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item Group
Unnamed2
Item
Please assess breast cosmesis at this time
text
C25367 (NCI Thesaurus Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
CL.5
Code List
Please assess breast cosmesis at this time
CL Item
Excellent (Excellent)
CL Item
Good (Good)
CL Item
Fair (Fair)
CL Item
Poor (Poor)
Item
Skin telangiectasia
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C28194 (NCI Thesaurus Property)
C0039446 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.6
Code List
Skin telangiectasia
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Skin atrophy
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C79748 (NCI Thesaurus Property)
C0333641 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.7
Code List
Skin atrophy
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Scarring
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C34483 (NCI Thesaurus Property)
C2004491 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.8
Code List
Scarring
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Pigment change
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C747 (NCI Thesaurus Property)
C0031916 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.9
Code List
Pigment change
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Erythema
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C26901 (NCI Thesaurus Property)
C0041834 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
Erythema
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Fat necrosis
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C26772 (NCI Thesaurus Property)
C0015668 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.11
Code List
Fat necrosis
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Fibrosis
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C3044 (NCI Thesaurus Property)
C0016059 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.12
Code List
Fibrosis
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Retraction or contour defect
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43429 (NCI Thesaurus Property)
C1457869 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.13
Code List
Retraction or contour defect
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Volume loss
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25559 (NCI Thesaurus Property)
C1517945 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.14
Code List
Volume loss
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
Item
Other significant treatment effect
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.15
Code List
Other significant treatment effect
CL Item
None (None)
CL Item
Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
CL Item
Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
BreastReconstructionOtherAssessmentSpecify
Item
Specify
text
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25351 (NCI Thesaurus ObjectClass)
C0524865 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Footer Module
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
ResponsiblePersonSignatureText
Item
Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
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