ID

42648

Description

RTOG 1016 FQ: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Work Status Questionnaire Radiation Therapy With Cisplatin or Cetuximab in Treating Patients With Oropharyngeal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=953353B4-562C-83C2-E040-BB89AD433EAB

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=953353B4-562C-83C2-E040-BB89AD433EAB

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/17/21 9/17/21 -
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September 17, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT01302834 Quality of Life - RTOG 1016 FQ: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Work Status Questionnaire - 3160066v1.0

English

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms  
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

Protocol ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Description

Institution Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Description

Trial subject ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Amended data
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Eortc Qlq-h&n35
Description

Eortc Qlq-h&n35

Patient gender
Description

PersonGenderTextType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17357
UMLS 2011AA Property
C0079399
Patient Age
Description

PatientAgeValue

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
Patient Ethnicity
Description

EthnicGroupCategoryText

Data type

text

Alias
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16564
UMLS 2011AA ObjectClass
C0015031
Patient Race
Description

RaceCategoryText

Data type

text

Alias
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C17049
UMLS 2011AA ObjectClass
C0034510
Paternal Race
Description

PaternalRaceCategory

Data type

text

Alias
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C17049
UMLS 2011AA ObjectClass
C0034510
NCI Metathesaurus Property
CL162064
Maternal Race
Description

MaternalRaceCategory

Data type

text

Alias
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C17049
UMLS 2011AA ObjectClass
C0034510
NCI Thesaurus Property-2
C89336
Marital Status
Description

PersonMaritalStatusCategory

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus Property
C25188
UMLS 2011AA Property
C0024819
Where do you live now
Description

PatientResidenceRadiationTherapyOncologyGroupType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain-2
C19778
UMLS 2011AA ValueDomain-2
C1514695
NCI Thesaurus Property
C25273
UMLS 2011AA Property
C0237096
Which of the following best describes your current work status
Description

CurrentEmploymentDescriptionStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C25172
UMLS 2011AA ObjectClass-2
C0014003
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Please specify (Other)
Description

CurrentEmploymentDescriptionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C25172
UMLS 2011AA ObjectClass-2
C0014003
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Highest educational level
Description

PersonEducationLevelSummaryRadiationTherapyOncologyGroupType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C17953
UMLS 2011AA Property
C0013658
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ValueDomain-2
C19778
UMLS 2011AA ValueDomain-2
C1514695
NCI Thesaurus ValueDomain-3
C17953
UMLS 2011AA ValueDomain-3
C0013658
NCI Thesaurus ValueDomain-4
C42581
UMLS 2011AA ValueDomain-4
C1706244
In the year before you were diagnosed with ORAL/OROPHARYNX cancer, about how many months did you work?
Description

EmploymentPastInteger::12MonthCount

Data type

text

Alias
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property
C45255
UMLS 2011AA Property
C1708523
NCI Thesaurus Property-2
C29846
UMLS 2011AA Property-2
C0439231
NCI Thesaurus Property-3
C25609
UMLS 2011AA Property-3
C1444637
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ValueDomain-2
C19778
UMLS 2011AA ValueDomain-2
C1514695
How many hours per week do you work?
Description

EmploymentWeekHourCount

Data type

float

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25529
UMLS 2011AA Property
C0439227
NCI Thesaurus Property-2
C29844
UMLS 2011AA Property-2
C0439230
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
Which industry would you say best describes your workplace?
Description

EmploymentDescriptionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Please specify
Description

EmploymentDescriptionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Which occupational category best describes your work?
Description

EmploymentCategoryDescriptionType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
Please specify
Description

EmploymentCategoryDescriptionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25372
UMLS 2011AA Property
C0683312
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
Are you covered by a health plan provided through your current or former employer or union?
Description

EmploymentHealthInsuranceIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C16745
UMLS 2011AA Property
C0021672
NCI Thesaurus Property-2
C25178
UMLS 2011AA Property-2
C0018684
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
In addition to you, who else in your household is covered by your insurance plan?
Description

EmploymentHealthOtherPersonInsuranceType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property-2
C25190
UMLS 2011AA Property-2
C0027361
NCI Thesaurus Property-3
C16745
UMLS 2011AA Property-3
C0021672
NCI Thesaurus Property-4
C25178
UMLS 2011AA Property-4
C0018684
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
If you needed it, would you get any paid sick leave or disability benefits from your current job
Description

EmploymentBenefitsIndicator

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
NCI Thesaurus Property
C25387
UMLS 2011AA Property
C0814225
Which category is closest to your INDIVIDUAL total income during the year before your oral/oropharynx cancer diagnosis?
Description

IndividualIncomeRange

Data type

text

Alias
NCI Thesaurus Property
C41150
UMLS 2011AA Property
C0021162
NCI Thesaurus ObjectClass
C17719
NCI Thesaurus ValueDomain
C38013
UMLS 2011AA ValueDomain
C1514721
Which category is closest to your household's total COMBINED income during the year before your oral/oropharynx cancer diagnosis?
Description

PersonHouseholdIncomeRange

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C70811
UMLS 2011AA Property
C0557163
NCI Thesaurus ValueDomain
C38013
UMLS 2011AA ValueDomain
C1514721
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Amended data
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Eortc Qlq-h&n35
Item
Patient gender
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
CL.2
Code List
Patient gender
CL Item
Male Gender (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female Gender (Female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
PatientAgeValue
Item
Patient Age
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
Item
Patient Ethnicity
text
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16564 (NCI Thesaurus ObjectClass)
C0015031 (UMLS 2011AA ObjectClass)
CL.3
Code List
Patient Ethnicity
CL Item
Hispanic Or Latino (Hispanic or Latino)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
Not Hispanic Or Latino (Not Hispanic or Latino)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
Item
Patient Race
text
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)
CL.4
Code List
Patient Race
CL Item
American Indian Or Alaska Native (American Indian or Alaska Native)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
CL Item
Asian (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
Black Or African American (Black or African American)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
Not Reported (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
White (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
Item
Paternal Race
text
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)
CL162064 (NCI Metathesaurus Property)
CL.5
Code List
Paternal Race
CL Item
American Indian Or Alaska Native (American Indian or Alaska Native)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
CL Item
Asian (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
Black Or African American (Black or African American)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
Not Reported (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
White (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
Item
Maternal Race
text
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C17049 (NCI Thesaurus ObjectClass)
C0034510 (UMLS 2011AA ObjectClass)
C89336 (NCI Thesaurus Property-2)
CL.6
Code List
Maternal Race
CL Item
American Indian Or Alaska Native (American Indian or Alaska Native)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
CL Item
Asian (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
Black Or African American (Black or African American)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
CL Item
Native Hawaiian Or Other Pacific Islander (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
Not Reported (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
White (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
Item
Marital Status
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25188 (NCI Thesaurus Property)
C0024819 (UMLS 2011AA Property)
CL.7
Code List
Marital Status
CL Item
Divorced: C51776 (Divorced)
C51776 (NCI Thesaurus)
C0086170 (UMLS 2011AA)
CL Item
Domestic Partner (Domestic Partnership)
C53262 (NCI Thesaurus)
C1549111 (UMLS 2011AA)
CL Item
Married: C51773 (Married)
C51773 (NCI Thesaurus)
C0555047 (UMLS 2011AA)
CL Item
Never Married (Never Married)
C51774 (NCI Thesaurus)
C0027952 (UMLS 2011AA)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS 2011AA)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
Item
Where do you live now
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ValueDomain-2)
C1514695 (UMLS 2011AA ValueDomain-2)
C25273 (NCI Thesaurus Property)
C0237096 (UMLS 2011AA Property)
CL.8
Code List
Where do you live now
CL Item
Homeless Or Homeless Shelter (Homeless or homeless shelter)
CL Item
In A Condominium Or House That You Own (In a condominium or house that you own)
CL Item
In A Rented Apartment Or House Where You Pay All Of The Bills (In a rented apartment or house where you pay all of the bills)
CL Item
In A Rented Apartment Or House Where You Pay Some Of The Bills (In a rented apartment or house where you pay some of the bills)
CL Item
In Public Assistance Housing (In public assistance housing)
CL Item
Living With Relative Or Friends Who Pay All The Bills (Living with relative or friends who pay all the bills)
CL Item
Other (Other)
Item
Which of the following best describes your current work status
text
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C25172 (NCI Thesaurus ObjectClass-2)
C0014003 (UMLS 2011AA ObjectClass-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.9
Code List
Which of the following best describes your current work status
CL Item
Not Working Outside Of The Home (Not working outside of the home)
CL Item
Student, Full-time (Student, full-time)
CL Item
Student, Part-time (Student, part-time)
CL Item
Currently Working In At Least One Full Time Job (Currently working in at least one FULL time job)
CL Item
Currently Working In At Least One Part Time Job (Currently working in at least one PART time job)
CL Item
Unknown (Don't know)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Not Employed (Not employed)
CL Item
On Disability (On disability)
CL Item
On Sick Leave (On sick leave)
CL Item
Other (Other)
CL Item
Retired (Retired)
CurrentEmploymentDescriptionSpecify
Item
Please specify (Other)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C25172 (NCI Thesaurus ObjectClass-2)
C0014003 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Highest educational level
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C17953 (NCI Thesaurus Property)
C0013658 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19778 (NCI Thesaurus ValueDomain-2)
C1514695 (UMLS 2011AA ValueDomain-2)
C17953 (NCI Thesaurus ValueDomain-3)
C0013658 (UMLS 2011AA ValueDomain-3)
C42581 (NCI Thesaurus ValueDomain-4)
C1706244 (UMLS 2011AA ValueDomain-4)
CL.10
Code List
Highest educational level
CL Item
Graduation Or Professional Degree (Advanced degree)
C37998 (NCI Thesaurus)
C1518602 (UMLS 2011AA)
C52581 (NCI Thesaurus-3)
C1711333 (UMLS 2011AA-4)
C75558 (NCI Thesaurus-5)
C2698884 (UMLS 2011AA-6)
C25354 (NCI Thesaurus-7)
C0542560 (UMLS 2011AA-8)
CL Item
Bachelor's Degree (Bachelor's Degree)
C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)
CL Item
Grade School (Grade School)
C80410 (NCI Thesaurus)
C0683859 (UMLS 2011AA)
CL Item
High School Completion Or General Equivalency Diploma (ged) Completion (High school graduate (including equivalency))
C67136 (NCI Thesaurus)
C0870649 (UMLS 2011AA)
C37998 (NCI Thesaurus-3)
C1518602 (UMLS 2011AA-4)
C67135 (NCI Thesaurus-5)
C1880947 (UMLS 2011AA-6)
CL Item
No Formal Schooling (No formal education)
C67122 (NCI Thesaurus)
C0557286 (UMLS 2011AA)
CL Item
Not High School Graduate (Not high school graduate)
C76123 (NCI Thesaurus)
C2825140 (UMLS 2011AA)
CL Item
Some College Or Associates Degree (Some college or associate degree)
C37998 (NCI Thesaurus)
C1518602 (UMLS 2011AA)
C71340 (NCI Thesaurus-3)
C1549943 (UMLS 2011AA-4)
C65099 (NCI Thesaurus-5)
C0205392 (UMLS 2011AA-6)
C61514 (NCI Thesaurus-7)
C0557806 (UMLS 2011AA-8)
CL Item
Went To Vocational/technical School (Went to vocational/technical school)
Item
In the year before you were diagnosed with ORAL/OROPHARYNX cancer, about how many months did you work?
text
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C45255 (NCI Thesaurus Property)
C1708523 (UMLS 2011AA Property)
C29846 (NCI Thesaurus Property-2)
C0439231 (UMLS 2011AA Property-2)
C25609 (NCI Thesaurus Property-3)
C1444637 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19778 (NCI Thesaurus ValueDomain-2)
C1514695 (UMLS 2011AA ValueDomain-2)
CL.11
Code List
In the year before you were diagnosed with ORAL/OROPHARYNX cancer, about how many months did you work?
CL Item
I Did Not Do Paid Work (0 Months) (I did not do paid work (0 months))
CL Item
1 Month (1 month)
CL Item
2 Months (2 months)
CL Item
3 Months (3 months)
CL Item
4 Months (4 months)
CL Item
5 Months (5 months)
CL Item
6 Months (6 months)
CL Item
7 Months (7 months)
CL Item
8 Months (8 months)
CL Item
9 Months (9 months)
CL Item
10 Months (10 months)
CL Item
11 Months (11 months)
CL Item
12 Months (12 months)
EmploymentWeekHourCount
Item
How many hours per week do you work?
float
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25529 (NCI Thesaurus Property)
C0439227 (UMLS 2011AA Property)
C29844 (NCI Thesaurus Property-2)
C0439230 (UMLS 2011AA Property-2)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
Item
Which industry would you say best describes your workplace?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.12
Code List
Which industry would you say best describes your workplace?
CL Item
Construction (Construction)
CL Item
Education (Education)
C16529 (NCI Thesaurus)
C0013622 (UMLS 2011AA)
CL Item
Finance, Insurance, Or Real Estate (Finance, insurance, or real estate)
CL Item
Government (Government)
CL Item
Legal (Legal)
C97637 (NCI Thesaurus)
CL Item
Manufacturing (Manufacturing)
CL Item
Medical (Medical)
CL Item
Other (Other)
CL Item
Retail Trade (Retail trade)
CL Item
Service (Service)
CL Item
Transportation And Public Utilities (Transportation and public utilities)
CL Item
Wholesale Trade (Wholesale trade)
EmploymentDescriptionSpecify
Item
Please specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Which occupational category best describes your work?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
CL.13
Code List
Which occupational category best describes your work?
CL Item
Arts, Media Or Athletics (Arts, media or athletics)
CL Item
Managerial Or Professional Specialty (Managerial or professional specialty)
CL Item
Operator, Fabricator, Or Laborer (Operator, fabricator, or laborer)
CL Item
Other (Other)
CL Item
Sales, Technical, Or Administrative Support (Sales, technical, or administrative support)
CL Item
Service (Service)
EmploymentCategoryDescriptionSpecify
Item
Please specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25372 (NCI Thesaurus Property)
C0683312 (UMLS 2011AA Property)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
Item
Are you covered by a health plan provided through your current or former employer or union?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16745 (NCI Thesaurus Property)
C0021672 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property-2)
C0018684 (UMLS 2011AA Property-2)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
CL.14
Code List
Are you covered by a health plan provided through your current or former employer or union?
CL Item
Don't Know (Don't know)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
In addition to you, who else in your household is covered by your insurance plan?
text
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25190 (NCI Thesaurus Property-2)
C0027361 (UMLS 2011AA Property-2)
C16745 (NCI Thesaurus Property-3)
C0021672 (UMLS 2011AA Property-3)
C25178 (NCI Thesaurus Property-4)
C0018684 (UMLS 2011AA Property-4)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
In addition to you, who else in your household is covered by your insurance plan?
CL Item
Don't Know (Don't know)
CL Item
Myself And Child(ren) (myself and child(ren))
CL Item
Myself And Spouse And Child(ren) (myself and spouse and child(ren))
CL Item
Myself And Spouse Only (myself and spouse only)
CL Item
Myself Only (myself only)
Item
If you needed it, would you get any paid sick leave or disability benefits from your current job
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
C25387 (NCI Thesaurus Property)
C0814225 (UMLS 2011AA Property)
CL.16
Code List
If you needed it, would you get any paid sick leave or disability benefits from your current job
CL Item
Don't Know (Don't know)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Which category is closest to your INDIVIDUAL total income during the year before your oral/oropharynx cancer diagnosis?
text
C41150 (NCI Thesaurus Property)
C0021162 (UMLS 2011AA Property)
C17719 (NCI Thesaurus ObjectClass)
C38013 (NCI Thesaurus ValueDomain)
C1514721 (UMLS 2011AA ValueDomain)
CL.17
Code List
Which category is closest to your INDIVIDUAL total income during the year before your oral/oropharynx cancer diagnosis?
CL Item
$10,000 To $19,999 ($10,000 to $19,999)
CL Item
$100,000 To $149,999 ($100,000 to $149,999)
CL Item
$150,000 To $199,999 ($150,000 to $199,999)
CL Item
$20,000 To $29,999 ($20,000 to $29,999)
CL Item
$200,000 Or More ($200,000 or more)
CL Item
$30,000 To $39,999 ($30,000 to $39,999)
CL Item
$40,000 To $49,999 ($40,000 to $49,999)
CL Item
$50,000 To $59,999 ($50,000 to $59,999)
CL Item
$60,000 To $69,999 ($60,000 to $69,999)
CL Item
$70,000 To $79,999 ($70,000 to $79,999)
CL Item
$80,000 To $89,999 ($80,000 to $89,999)
CL Item
$90,000 To $99,999 ($90,000 to $99,999)
CL Item
Less Than $10,000 (Less than $10,000)
Item
Which category is closest to your household's total COMBINED income during the year before your oral/oropharynx cancer diagnosis?
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C70811 (NCI Thesaurus Property)
C0557163 (UMLS 2011AA Property)
C38013 (NCI Thesaurus ValueDomain)
C1514721 (UMLS 2011AA ValueDomain)
CL.18
Code List
Which category is closest to your household's total COMBINED income during the year before your oral/oropharynx cancer diagnosis?
CL Item
$10,000 To $19,999 ($10,000 to $19,999)
CL Item
$100,000 To $149,999 ($100,000 to $149,999)
CL Item
$150,000 To $199,999 ($150,000 to $199,999)
CL Item
$20,000 To $29,999 ($20,000 to $29,999)
CL Item
$200,000 Or More ($200,000 or more)
CL Item
$30,000 To $39,999 ($30,000 to $39,999)
CL Item
$40,000 To $49,999 ($40,000 to $49,999)
CL Item
$50,000 To $59,999 ($50,000 to $59,999)
CL Item
$60,000 To $69,999 ($60,000 to $69,999)
CL Item
$70,000 To $79,999 ($70,000 to $79,999)
CL Item
$80,000 To $89,999 ($80,000 to $89,999)
CL Item
$90,000 To $99,999 ($90,000 to $99,999)
CL Item
Less Than $10,000 (Less than $10,000)
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