ID

3435

Descrizione

COVER SHEET 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=A6631050-8DCA-48C7-E034-0003BA0B1A09

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A6631050-8DCA-48C7-E034-0003BA0B1A09

Keywords

versioni (3)
  1. 20/09/12 20/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
  3. 03/07/15 03/07/15 -
Caricato su

20 settembre 2012

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00075686 Quality of Life - COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205 - 2049414v3.0

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Unnamed1
Descrizione

Unnamed1

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient Initials (L, F M)
Descrizione

PatientInitialsName

Tipo di dati

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
Descrizione

PlannedAssessment

Tipo di dati

text

Institution
Descrizione

InstitutionName

Tipo di dati

text

Affiliate
Descrizione

AffiliateName

Tipo di dati

text

Physician
Descrizione

RegisteredInvestigator

Tipo di dati

text

Unnamed3
Descrizione

Unnamed3

Unnamed4
Descrizione

Unnamed4

Was the Brief Pain Inventory completed?
Descrizione

WastheBriefPainInventorycompleted?

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If the Brief Pain Inventory Not completed, Please give reason (select one)
Descrizione

IftheBriefPainInventoryNotcompleted,Pleasegivereason

Tipo di dati

text

Was the LASA Patient Quality of Life Questionnaire completed? (If Yes,)
Descrizione

WastheLASAPatientQualityofLifeQuestionnairecompleted?

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date (1.)
Descrizione

SymptomAssessmentDate

Tipo di dati

date

Date (1.)
Descrizione

SymptomAssessmentDate

Tipo di dati

date

Which types of assistance were required? (select all that apply)
Descrizione

Whichtypesofassistancewererequired?

Tipo di dati

text

Which types of assistance were required? (select all that apply)
Descrizione

Whichtypesofassistancewererequired?

Tipo di dati

text

If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
Descrizione

IfLASAPatientQualityofLifeQuestionnaireNotcompleted,Pleasegivereason

Tipo di dati

text

Other (specify)
Descrizione

LymphNodeSamplingOtherExtent

Tipo di dati

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Other (specify)
Descrizione

LymphNodeSamplingOtherExtent

Tipo di dati

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Other (specify)
Descrizione

LymphNodeSamplingOtherExtent

Tipo di dati

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Other (specify)
Descrizione

Other(specify)

Tipo di dati

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Unnamed5
Descrizione

Unnamed5

BY
Descrizione

PersonCompletingForm,LastName

Tipo di dati

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PHONE
Descrizione

PersonCompletingForm,Phone

Tipo di dati

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

FormCompletionDate,Original

Tipo di dati

date

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
Descrizione

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
Descrizione

Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: COVER SHEET FOR PATIENT-COMPLETE QUESTIONNAIRES: S0205
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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)
InstitutionName
Item
Institution
text
AffiliateName
Item
Affiliate
text
RegisteredInvestigator
Item
Physician
text
Item Group
Unnamed3
Item Group
Unnamed4
Item
Was the Brief Pain Inventory completed?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.2
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
If the Brief Pain Inventory Not completed, Please give reason (select one)
text
CL.4
Code List
If the Brief Pain Inventory Not completed, Please give reason (select one)
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Institution Error (Institution error)
CL Item
Not Illness Related (Not illness related)
CL Item
Other (specify) (Other (specify))
Item
Was the LASA Patient Quality of Life Questionnaire completed? (If Yes,)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.5
Code List
Was the LASA Patient Quality of Life Questionnaire completed? (If Yes,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SymptomAssessmentDate
Item
Date (1.)
date
SymptomAssessmentDate
Item
Date (1.)
date
Item
Which types of assistance were required? (select all that apply)
text
CL.6
Code List
Which types of assistance were required? (select all that apply)
CL Item
No Assistance Required (No assistance required)
CL Item
Asked To Explain Meaning Of Terms (Asked to explain meaning of terms)
CL Item
Asked For Help With The Response Format (Asked for help with the response format)
CL Item
Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions. (Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions.)
CL Item
Needed Questionnaire Read Aloud But Able To Answer Questions On His/her Own (Needed questionnaire read aloud but able to answer questions on his/her own)
CL Item
Needed Questionnaire Read Aloud And Needed Nurse/cra To Write Patient Verbal Answers On Form (Needed questionnaire read aloud and needed nurse/CRA to write patient verbal answers on form)
CL Item
Other (specify) (Other (specify))
Item
Which types of assistance were required? (select all that apply)
text
CL.6
Code List
Which types of assistance were required? (select all that apply)
CL Item
No Assistance Required (No assistance required)
CL Item
Asked To Explain Meaning Of Terms (Asked to explain meaning of terms)
CL Item
Asked For Help With The Response Format (Asked for help with the response format)
CL Item
Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions. (Wanted help from family members to answer questions but you explained that this questionnaire should involve only his/her opinions.)
CL Item
Needed Questionnaire Read Aloud But Able To Answer Questions On His/her Own (Needed questionnaire read aloud but able to answer questions on his/her own)
CL Item
Needed Questionnaire Read Aloud And Needed Nurse/cra To Write Patient Verbal Answers On Form (Needed questionnaire read aloud and needed nurse/CRA to write patient verbal answers on form)
CL Item
Other (specify) (Other (specify))
Item
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
text
CL.7
Code List
If LASA Patient Quality of Life Questionnaire Not completed, Please give reason (select one)
CL Item
Illness/deteriorating Health (Illness/deteriorating health)
CL Item
Institution Error (Institution error)
CL Item
Not Illness Related (Not illness related)
CL Item
Other (specify) (Other (specify))
LymphNodeSamplingOtherExtent
Item
Other (specify)
text
LymphNodeSamplingOtherExtent
Item
Other (specify)
text
LymphNodeSamplingOtherExtent
Item
Other (specify)
text
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 Cover Sheet For Patient-complete Questionnaires: S0205
Item Group
Ccrr Module For Cover Sheet For Patient-complete Questionnaires: S0205
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