ID

3101

Beschrijving

A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2 Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CB05D-071D-28BA-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CB05D-071D-28BA-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 11-08-14 11-08-14 - Martin Dugas
  3. 22-03-15 22-03-15 - Martin Dugas
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19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT00023829 Demographic - A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2 - 2038335v3.0

Engels

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling boxes or blanks as requested. See separate page for instructions

1 Formulieren  
Unnamed1
Beschrijving

Unnamed1

Date Completed (mm/dd/yyyy)
Beschrijving

DateCompleted

Datatype

date

Unnamed2
Beschrijving

Unnamed2

RTOG Study
Beschrijving

RTOGStudy

Datatype

text

Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

Institution

Datatype

text

Institution #
Beschrijving

Institution#

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Name
Beschrijving

PatientName

Datatype

text

Patient ID # (10. Family History)
Beschrijving

PatientID#

Datatype

text

Unnamed3
Beschrijving

Unnamed3

If this is a revised or corrected form, indicate by checking box. (1.)
Beschrijving

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Datatype

text

Unnamed4
Beschrijving

Unnamed4

Who completed this form? (Check one box)
Beschrijving

Whocompletedthisform?

Datatype

text

Race (Check one box only)
Beschrijving

PatientRace

Datatype

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17049
UMLS 2011AA Property
C0034510
Other, specify (race) (2B.)
Beschrijving

Other,specify(race)

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Beschrijving

AdditionalRace/Ethnicity

Datatype

text

Highest school grade completed (Check one box)
Beschrijving

Highestschoolgradecompleted

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C16529
UMLS 2011AA Property
C0013622
NCI Thesaurus Property
C25525
UMLS 2011AA Property
C1522410
Other, specify (highest school grade completed) (4.)
Beschrijving

Other,specify(highestschoolgradecompleted)

Datatype

text

Religion during childhood (Check one box)
Beschrijving

PersonPediatricReligionName

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C39299
UMLS 2011AA Property
C0231335
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property
C17085
UMLS 2011AA Property
C0035039
Other, specify (religion during childhood) (5.)
Beschrijving

Other,specify(religionduringchildhood)

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Marital status (Check one box)
Beschrijving

Maritalstatus

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Where were you born? (Check one box)
Beschrijving

Wherewereyouborn?

Datatype

text

Other country, specify (where you were born) (7.)
Beschrijving

Othercountry,specify(whereyouwereborn)

Datatype

text

Where did you live the longest (Check one box)
Beschrijving

Wheredidyoulivethelongest

Datatype

text

USA, specify the 2 letter State code, eg NY
Beschrijving

USA,specifythe2letterStatecode,egNY

Datatype

text

USA, specify the 2 letter State code, eg NY
Beschrijving

USA,specifythe2letterStatecode,egNY

Datatype

text

Other country, specify (where you lived the longest) (8. Cigarette History?)
Beschrijving

Othercountry,specify(whereyoulivedthelongest)

Datatype

text

Smoked at least 100 cigarette (5 packs) during lifetime (B.)
Beschrijving

SmokingHistoryAssessmentIndicator

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C29719
UMLS 2011AA ObjectClass
C1519384
Age began smoking cigarettes (C.)
Beschrijving

PatientInitialCigaretteSmokingAgeYearCount

Datatype

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
NCI Thesaurus Property
C18270
UMLS 2011AA Property
C0700219
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of years smoked cigarettes (D.)
Beschrijving

Numberofyearssmokedcigarettes

Datatype

text

Average number of cigarettes smoked per day (E.)
Beschrijving

Averagenumberofcigarettessmokedperday

Datatype

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If quit, age stopped smoking completely (9.)
Beschrijving

PatientSmokingCessationAgeYear

Datatype

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Metathesaurus Property
C0085134
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
Beschrijving

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Datatype

text

Specify other (illness)
Beschrijving

Specifyother(illness)

Datatype

text

Unnamed5
Beschrijving

Unnamed5

RTOG Study
Beschrijving

RTOGStudy

Datatype

text

Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

Institution

Datatype

text

Institution #
Beschrijving

Institution#

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Name
Beschrijving

PatientName

Datatype

text

Patient ID # (10. Family History)
Beschrijving

PatientID#

Datatype

text

Unnamed6
Beschrijving

Unnamed6

Brothers
Beschrijving

Brothers

Datatype

text

Sisters
Beschrijving

Sisters

Datatype

text

Sons
Beschrijving

Sons

Datatype

text

Daughters (B.)
Beschrijving

Daughters

Datatype

text

Are you adopted? (Check one)
Beschrijving

Areyouadopted?

Datatype

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25290
UMLS 2011AA Property
C0425382
Unnamed7
Beschrijving

Unnamed7

Blood relative with cancer (X = yes 2)
Beschrijving

Bloodrelativewithcancer

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Age when first cancer diagnosed
Beschrijving

PersonFirstCancerDiagnosisAgeYearCount

Datatype

double

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C9305
UMLS 2011AA Property
C0006826
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Type of Cancer
Beschrijving

TypeofCancer

Datatype

text

specify (other cancers) (11A.)
Beschrijving

specify(othercancers)

Datatype

text

Unnamed8
Beschrijving

Unnamed8

Have you ever heard of Cancer Prevention Trials? (Check one box)
Beschrijving

CancerPreventionTrialKnowledgeDocumentedInd-2

Datatype

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Metathesaurus Property
C0376554
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
Beschrijving

CancerPreventionTrialParticipationScale

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus ObjectClass
C15790
UMLS 2011AA ObjectClass
C1516220
Ccrr Module For A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2
Beschrijving

Ccrr Module For A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2

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Similar models

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling boxes or blanks as requested. See separate page for instructions

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
DateCompleted
Item
Date Completed (mm/dd/yyyy)
date
Item Group
Unnamed2
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
Institution
Item
Institution
text
Institution#
Item
Institution #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID # (10. Family History)
text
Item Group
Unnamed3
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box. (1.)
text
Item Group
Unnamed4
Item
Who completed this form? (Check one box)
text
CL.1
Code List
Who completed this form? (Check one box)
CL Item
Self (Self)
C25200 (NCI Thesaurus)
C0036588 (UMLS 2011AA)
CL Item
Staff (Staff)
CL Item
Other Person (Other person)
CL Item
Not Applicable, No Items Completed (Not applicable, no items completed)
Item
Race (Check one box only)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
CL.2
Code List
Race (Check one box only)
CL Item
White, Not Hispanic Origin (White, not Hispanic origin)
CL Item
Hispanic (Hispanic)
CL Item
Black, Not Hispanic Origin (Black, not Hispanic origin)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
CL Item
Asian (Asian)
CL Item
Native American / Alaskan Nation (Native American / Alaskan Nation)
CL Item
Other, specify (Other, specify)
CL Item
Unknown / I Prefer Not To Answer (Unknown / I prefer not to answer)
Other,specify(race)
Item
Other, specify (race) (2B.)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
text
CL.3
Code List
Additional Race/Ethnicity (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
CL Item
White, Not Hispanic Origin (White, not Hispanic origin)
CL Item
Hispanic (Hispanic)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
Black, Not Hispanic Origin (Black, not Hispanic origin)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
CL025744 (NCI Metathesaurus)
CL Item
Asian (Asian)
CL106519 (NCI Metathesaurus)
CL Item
Native American / Alaskan Nation (Native American / Alaskan Nation)
CL Item
Unknown / I Prefer Not To Answer (Unknown / I prefer not to answer)
Item
Highest school grade completed (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16529 (NCI Thesaurus Property)
C0013622 (UMLS 2011AA Property)
C25525 (NCI Thesaurus Property)
C1522410 (UMLS 2011AA Property)
CL.4
Code List
Highest school grade completed (Check one box)
CL Item
8th Or Less (8th or less)
CL Item
9 - 11th Grade (9 - 11th Grade)
CL Item
High School Graduate / Ged (High school graduate / GED)
CL Item
Vocational / Technical School (Vocational / technical school)
CL Item
Associate Degree / Some College (Associate degree / some college)
CL Item
Bachelor's Degree (Bachelor's degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Advanced Degree (Advanced degree)
CL Item
Other, Specify (Other, specify)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(highestschoolgradecompleted)
Item
Other, specify (highest school grade completed) (4.)
text
Item
Religion during childhood (Check one box)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C39299 (NCI Thesaurus Property)
C0231335 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C17085 (NCI Thesaurus Property)
C0035039 (UMLS 2011AA Property)
CL.5
Code List
Religion during childhood (Check one box)
CL Item
Protestant (Protestant)
CL Item
Catholic (Catholic)
CL Item
Jewish (Jewish)
C0178443 (NCI Metathesaurus)
CL Item
Morman/latter Day Saints (Morman/Latter Day Saints)
CL Item
Muslim / Islam (Muslim / Islam)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Other,specify(religionduringchildhood)
Item
Other, specify (religion during childhood) (5.)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Marital status (Check one box)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Marital status (Check one box)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
CL Item
Single (Single)
CL Item
Divorced/separated (Divorced/Separated)
CL Item
Living As Married (Living as married)
CL Item
I Prefer Not To Answer (I prefer not to answer)
Item
Where were you born? (Check one box)
text
CL.7
Code List
Where were you born? (Check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA, specify the 2 letter State code, eg NY)
CL Item
Other Country, Specify (Other country, specify)
Othercountry,specify(whereyouwereborn)
Item
Other country, specify (where you were born) (7.)
text
Item
Where did you live the longest (Check one box)
text
CL.8
Code List
Where did you live the longest (Check one box)
CL Item
Usa, Specify The 2 Letter State Code, Eg Ny (USA, specify the 2 letter State code, eg NY)
CL Item
Other Country, Specify (Other country, specify)
USA,specifythe2letterStatecode,egNY
Item
USA, specify the 2 letter State code, eg NY
text
USA,specifythe2letterStatecode,egNY
Item
USA, specify the 2 letter State code, eg NY
text
Othercountry,specify(whereyoulivedthelongest)
Item
Other country, specify (where you lived the longest) (8. Cigarette History?)
text
Item
Smoked at least 100 cigarette (5 packs) during lifetime (B.)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C29719 (NCI Thesaurus ObjectClass)
C1519384 (UMLS 2011AA ObjectClass)
CL.9
Code List
Smoked at least 100 cigarette (5 packs) during lifetime (B.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, But Quit (Yes, but quit)
CL Item
Yes, Currently Smoke (Yes, currently smoke)
PatientInitialCigaretteSmokingAgeYearCount
Item
Age began smoking cigarettes (C.)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property)
C0700219 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Numberofyearssmokedcigarettes
Item
Number of years smoked cigarettes (D.)
text
Averagenumberofcigarettessmokedperday
Item
Average number of cigarettes smoked per day (E.)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientSmokingCessationAgeYear
Item
If quit, age stopped smoking completely (9.)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C0085134 (NCI Metathesaurus Property)
Item
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
text
CL.10
Code List
If you have had any of the illness listed below, please check yes for those that apply. (X = Yes 2)
CL Item
Heart Problems (Heart problems)
CL Item
Lung Problems (Lung problems)
CL Item
High Blood Pressure (High blood pressure)
CL Item
Bleeding Problems (Bleeding problems)
CL Item
Circulation Problems (Circulation problems)
CL Item
Liver Problems (Liver problems)
CL Item
Diabetes Or Sugar In Urine (Diabetes or sugar in urine)
CL Item
Kidney/urine Problems (Kidney/urine problems)
CL Item
Stroke (Stroke)
CL Item
Thyroid Problems (Thyroid problems)
CL Item
Seizure (Seizure)
C2962 (NCI Thesaurus)
C0036572 (UMLS 2011AA)
CL Item
Hiv/aids (HIV/AIDS)
CL Item
Frequent Infections (Frequent infections)
CL Item
Psychological Problems (Psychological problems)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Specifyother(illness)
Item
Specify other (illness)
text
Item Group
Unnamed5
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
Institution
Item
Institution
text
Institution#
Item
Institution #
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID # (10. Family History)
text
Item Group
Unnamed6
Brothers
Item
Brothers
text
Sisters
Item
Sisters
text
Sons
Item
Sons
text
Daughters
Item
Daughters (B.)
text
Item
Are you adopted? (Check one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)
CL.11
Code List
Are you adopted? (Check one)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed7
Item
Blood relative with cancer (X = yes 2)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.12
Code List
Blood relative with cancer (X = yes 2)
CL Item
Father (Father)
C25174 (NCI Thesaurus)
C0015671 (UMLS 2011AA)
CL Item
Mother (Mother)
C25189 (NCI Thesaurus)
C0026591 (UMLS 2011AA)
CL Item
Brother #1 (Brother #1)
CL Item
Brother #2 (Brother #2)
CL Item
Brother #3 (Brother #3)
CL Item
Brother #4 (Brother #4)
CL Item
Sister #1 (Sister #1)
CL Item
Sister #2 (Sister #2)
CL Item
Sister #3 (Sister #3)
CL Item
Sister #4 (Sister #4)
CL Item
Child #1 (Child #1)
CL Item
Child #2 (Child #2)
CL Item
Child #3 (Child #3)
CL Item
Child #4 (Child #4)
PersonFirstCancerDiagnosisAgeYearCount
Item
Age when first cancer diagnosed
double
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Type of Cancer
text
CL.13
Code List
Type of Cancer
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Breast (Breast)
C12971 (NCI Thesaurus)
C0006141 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Prostate (Prostate)
C12410 (NCI Thesaurus)
C0033572 (UMLS 2011AA)
CL Item
Head & Neck (Head & Neck)
CL Item
Non Melanoma Skin (Non Melanoma Skin)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
specify(othercancers)
Item
specify (other cancers) (11A.)
text
Item Group
Unnamed8
Item
Have you ever heard of Cancer Prevention Trials? (Check one box)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C0376554 (NCI Metathesaurus Property)
CL.14
Code List
Have you ever heard of Cancer Prevention Trials? (Check one box)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C15790 (NCI Thesaurus ObjectClass)
C1516220 (UMLS 2011AA ObjectClass)
CL.15
Code List
How likely would you be to volunteer to participate in Cancer Prevention Trials? (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)
CL Item
1 (1)
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2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
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3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
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7 (7)
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8 (8)
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9 (9)
CL Item
10 (10)
Item Group
Ccrr Module For A5 Radiation Therapy Oncology Group Demographic Data Form - Version 2
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