ID

2939

Description

COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205 S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B186CE8D-98A1-0591-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B186CE8D-98A1-0591-E034-0003BA12F5E7

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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Pancreatic Cancer NCT00075686 Quality of Life - COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205 - 2075007v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

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
Unnamed2
Description

PlannedAssessment

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

DATE
Description

FormCompletionDate,Original

Data type

date

Physician
Description

RegisteredInvestigator

Data type

text

Unnamed3
Description

Unnamed3

Was the Pain Medication Log completed?
Description

PainPersonalLogCompleteInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C3303
UMLS 2011AA ObjectClass
C0030193
NCI Metathesaurus ObjectClass
C0872075
Was the Brief Pain Inventory completed?
Description

WastheBriefPainInventorycompleted?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Was the LASA Patient Quality of Life Questionnaire completed?
Description

WastheLASAPatientQualityofLifeQuestionnairecompleted?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Completed, In general did the patient require assistance?
Description

Ifcompleted,ingeneral,didthepatientrequireassistance?

Data type

text

Describe (If Yes,)
Description

Describe

Data type

text

If Completed, Questionnaire administered
Description

PatientQuestionnaireAdministeredMethodType

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C17048
UMLS 2011AA ObjectClass
C0034394
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other (please specify)
Description

PatientQuestionnaireAdministeredMethodSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C17048
UMLS 2011AA ObjectClass
C0034394
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
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
Other (specify)
Description

Other(specify)

Data type

text

Unnamed5
Description

Unnamed5

BY
Description

PersonCompletingForm,LastName

Data type

text

PHONE
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
DATE
Description

FormCompletionDate,Original

Data type

date

Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205
Description

Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205

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1 forms
  1. StudyEvent: COVERSHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
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)
Item
Unnamed2
text
CL.1
Code List
Unnamed2
CL Item
Prestudy (Prestudy)
CL Item
Week 5 (Week 5)
CL Item
Week 9 (Week 9)
CL Item
Week 13 (Week 13)
CL Item
Week 17 (Week 17)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
FormCompletionDate,Original
Item
DATE
date
RegisteredInvestigator
Item
Physician
text
Item Group
Unnamed3
Item
Was the Pain Medication Log completed?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C3303 (NCI Thesaurus ObjectClass)
C0030193 (UMLS 2011AA ObjectClass)
C0872075 (NCI Metathesaurus ObjectClass)
CL.2
Code List
Was the Pain Medication Log completed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Was the Brief Pain Inventory completed?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.3
Code List
Was the Brief Pain Inventory completed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Was the LASA Patient Quality of Life Questionnaire completed?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
Was the LASA Patient Quality of Life Questionnaire completed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
Describe
Item
Describe (If Yes,)
text
Item
If Completed, Questionnaire administered
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus ObjectClass)
C0034394 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
If Completed, Questionnaire administered
CL Item
In The Clinic (In the clinic)
CL Item
By Telephone (By telephone)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientQuestionnaireAdministeredMethodSpecify
Item
Other (please specify)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17048 (NCI Thesaurus ObjectClass)
C0034394 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
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)
Other(specify)
Item
Other (specify)
text
Item Group
Unnamed5
PersonCompletingForm,LastName
Item
BY
text
PersonCompletingForm,Phone
Item
PHONE
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
FormCompletionDate,Original
Item
DATE
date
Item Group
Ccrr Module For Coversheet For Patient-complete Questionnaires: S0205
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