ID

43915

Description

NCT00113399 RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EBAEDD99-A13F-1374-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EBAEDD99-A13F-1374-E034-0003BA3F9857

Keywords

Versions (2)
  1. 7/2/17 7/2/17 -
  2. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00113399 RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form

English

No Instruction available.

1 forms  
  1. StudyEvent: RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form
    1. No Instruction available.
RTOG clinical trial administrative data
Description

RTOG clinical trial administrative data

RTOG Study
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
Participant's Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participant's ID No.
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
Miscellaneous Patient Assessment
Description

Miscellaneous Patient Assessment

EQ-5D Questionnaire
Description

EQ-5D Questionnaire

Data type

text

Alias
UMLS CUI [1]
C2733251
Score
Description

PatientHealthScore

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25178
UMLS 2011AA Property
C0018684
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
Description

PatientSeriousSicknessInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus Property
C0221423
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
Description

ImmediateSeriousSicknessInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus ObjectClass
CL282488
NCI Metathesaurus Property
C0221423
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
Description

CareAssistantPatientSeriousSicknessInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
CL259930
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus Property
C0221423
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
WHAT IS YOUR AGE IN YEARS?
Description

PatientAgeYearCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
ARE YOU
Description

Gender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS CUI-1
C0079399
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17357
ARE YOU A current smoker
Description

Current Smoker

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C3241966
NCI Thesaurus Property
C25471
NCI Thesaurus ObjectClass
C17934
NCI Metathesaurus Property
C0449865
ARE YOU An ex-smoker
Description

Smoking use

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C3241966
NCI Thesaurus ObjectClass
C17934
NCI Thesaurus Property
C25340
ARE YOU A never smoker
Description

NoSmokingHistoryInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C49487
UMLS 2011AA ObjectClass
C1298908
NCI Thesaurus ObjectClass-2
C17934
UMLS 2011AA ObjectClass-2
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
Description

SocialWorkHistoryInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C17142
UMLS 2011AA ObjectClass
C0037441
IF SO, IN WHAT CAPACITY?
Description

SocialWorkHistoryRoleSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C17142
UMLS 2011AA ObjectClass
C0037441
NCI Thesaurus ValueDomain-2
C25199
UMLS 2011AA ValueDomain-2
C0035820
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
Description

Occupationstatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25193
UMLS 2011AA Property
C0028811
NCI Thesaurus ValueDomain-2
C25193
UMLS 2011AA ValueDomain-2
C0028811
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
Description

ContinuedEducationMinimumAgeatLeavingSchoolInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16529
UMLS 2011AA ObjectClass
C0013622
NCI Metathesaurus ObjectClass
C0750536
NCI Thesaurus Property
C25570
UMLS 2011AA Property
C1524031
NCI Metathesaurus Property
CL238333
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?
Description

PatientEducationalStatusInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0013658
IF YOU KNOW YOUR POSTCODE, WOULD YOU PLEASE WRITE IT HERE
Description

PatientAddressPostalCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25407
UMLS 2011AA Property
C1442065
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
RTOG clinical trial administrative data
Protocol ID RTOG
Item
RTOG Study
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
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
Participant's ID No.
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
Miscellaneous Patient Assessment
EQ-5D Questionnaire
Item
EQ-5D Questionnaire
text
C2733251 (UMLS CUI [1])
PatientHealthScore
Item
Score
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
PatientSeriousSicknessInd-2
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
ImmediateSeriousSicknessInd-2
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
CL282488 (NCI Metathesaurus ObjectClass)
C0221423 (NCI Metathesaurus Property)
CareAssistantPatientSeriousSicknessInd-2
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
CL259930 (NCI Metathesaurus ObjectClass)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientAgeYearCount
Item
WHAT IS YOUR AGE IN YEARS?
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
Item
ARE YOU
text
C25372 (NCI Thesaurus ValueDomain)
C0079399 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
CL.10
Code List
ARE YOU
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Current Smoker
Item
ARE YOU A current smoker
boolean
C38148 (NCI Thesaurus ValueDomain)
C3241966 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C17934 (NCI Thesaurus ObjectClass)
C0449865 (NCI Metathesaurus Property)
Smoking use
Item
ARE YOU An ex-smoker
boolean
C38148 (NCI Thesaurus ValueDomain)
C3241966 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C25340 (NCI Thesaurus Property)
NoSmokingHistoryInd-2
Item
ARE YOU A never smoker
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C49487 (NCI Thesaurus ObjectClass)
C1298908 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus ObjectClass-2)
C0453996 (UMLS 2011AA ObjectClass-2)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
SocialWorkHistoryInd-2
Item
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C17142 (NCI Thesaurus ObjectClass)
C0037441 (UMLS 2011AA ObjectClass)
SocialWorkHistoryRoleSpecify
Item
IF SO, IN WHAT CAPACITY?
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C17142 (NCI Thesaurus ObjectClass)
C0037441 (UMLS 2011AA ObjectClass)
C25199 (NCI Thesaurus ValueDomain-2)
C0035820 (UMLS 2011AA ValueDomain-2)
Item
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25193 (NCI Thesaurus Property)
C0028811 (UMLS 2011AA Property)
C25193 (NCI Thesaurus ValueDomain-2)
C0028811 (UMLS 2011AA ValueDomain-2)
CL.15
Code List
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
CL Item
Employed (In employment or self employment)
CL Item
Retired (Retired)
CL Item
Homemaker (Housework)
C75560 (NCI Thesaurus)
C0555052 (UMLS 2011AA)
CL Item
Student (Student)
CL Item
Unemployed (Seeking work)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
ContinuedEducationMinimumAgeatLeavingSchoolInd-2
Item
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
boolean
C16529 (NCI Thesaurus ObjectClass)
C0013622 (UMLS 2011AA ObjectClass)
C0750536 (NCI Metathesaurus ObjectClass)
C25570 (NCI Thesaurus Property)
C1524031 (UMLS 2011AA Property)
CL238333 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientEducationalStatusInd-2
Item
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0013658 (NCI Metathesaurus Property)
PatientAddressPostalCode
Item
IF YOU KNOW YOUR POSTCODE, WOULD YOU PLEASE WRITE IT HERE
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25407 (NCI Thesaurus Property)
C1442065 (UMLS 2011AA Property)
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