ID

5619

Beskrivning

A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 Radiation Therapy and Stereotactic Radiosurgery With or Without Temozolomide or Erlotinib in Treating Patients With Brain Metastases Secondary to Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D81B5AB0-2D5B-616A-E034-0003BA12F5E7

Nyckelord

D002289

Demographie

Uppladdad den

11 augusti 2014

DOI

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Creative Commons BY-NC 3.0 Legacy

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Lung Cancer NCT00096265 Demographic - A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 - 2277657v3.0

model
Detaljer

No Instruction available.

1 Formulär

StudyEvent: A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2
1. No Instruction available.

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

Header

Item Group

Header

ProtocolRTOGIdentifierNumber

Item

[RTOG Study No.]

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CL.1

Code List

[RTOG Study No.]

CL Item

RTOG Study 0320 (RTOG Study 0320)

Case#

Item

Case #

text

InstitutionName

Item

Institution

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

InstitutionIdentifierNumber

Item

Institution No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientInitialsName

Item

Participant's Initials

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)

PatientRadiationTherapyOncologyGroupIdentifierNumber

Item

Participant's I.D. No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

Module 1

Item Group

Module 1

FormOriginalCompleteDate

Item

Date Completed

date

C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

DataAmendedInd-3

Item

If this is a revised or corrected form, indicate by checking box.

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)

Module 2

Item Group

Module 2

Whocompletedthisform?

Item

Who completed this form? (check one box)

text

CL.2

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)

PatientRaceSpecify

Item

Other, specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)

PatientRaceCategory

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

C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)

CL.4

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

A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White, not Hispanic origin)

C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)

CL Item

Hispanic (Hispanic)

CL Item

Black, not Hispanic origin (Black, not Hispanic origin)

CL Item

A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)

CL Item

A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)

C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)

CL Item

A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (Native American/Alaskan Nation)

CL Item

Patient Is Unsure Of Their Race (Unknown/I prefer not to answer)

PatientRaceCategory

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.4

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

A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White, not Hispanic origin)

C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)

CL Item

Hispanic (Hispanic)

CL Item

Black, not Hispanic origin (Black, not Hispanic origin)

CL Item

A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)

CL Item

C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)

CL Item

Patient Is Unsure Of Their Race (Unknown/I prefer not to answer)

Highestschoolgradecompleted

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.5

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

Bachelor's Degree (Associate degree/some college)

C39327 (NCI Thesaurus)
C1511035 (UMLS 2011AA)

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)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

I Prefer Not To Answer (I prefer not to answer)

Other,specify(highestschoolgradecompleted)

Item

Other, specify

text

PersonPediatricReligionName

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.6

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)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

I Prefer Not To Answer (I prefer not to answer)

ReligionduringchildhoodOther,specify

Item

Other, specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

Maritalstatus

Item

Marital status (check one box)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.7

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)

Wherewereyouborn?

Item

Where were you born? (check one box Check the box of the country where you were born.)

text

CL.8

Code List

Where were you born? (check one box Check the box of the country where you were born.)

CL Item

Usa, Specify The 2 Letter State Code, Eg Ny (USA)

CL Item

Other Country, Specify (Other country)

Othercountry,specify(whereyouwereborn)

Item

Other country, specify

text

Wheredidyoulivethelongest

Item

Where did you live the longest (check one box)

text

CL.9

Code List

Where did you live the longest (check one box)

CL Item

Usa, Specify The 2 Letter State Code, Eg Ny (USA)

CL Item

Other Country, Specify (Other country)

USA,specifythe2letterStatecode,egNY

Item

specify the 2 letter State code, eg NY

text

USA,specifythe2letterStatecode,egNY

Item

specify the 2 letter State code, eg NY

text

Wheredidyoulivethelongest,othercountry,specify

Item

Other country, specify

text

Smoking history

Item

Smoked at least 100 cigarette (5 packs) during lifetime

text

C25180 (NCI Thesaurus ValueDomain)
C1519384 (UMLS CUI-1)
C20989 (NCI Thesaurus Property)
C29719 (NCI Thesaurus ObjectClass)

CL.10

Code List

Smoked at least 100 cigarette (5 packs) during lifetime

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

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

text

Averagenumberofcigarettessmokedperday

Item

Average number of cigarettes smoked per day

double

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)

PatientSmokingCessationAgeYear

Item

If quit, age stopped smoking completely

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)

Ifyouhavehadanyoftheillnesslistedbelow,pleasecheckyesforthosethatapply.

Item

If you have had any of the illness listed below, please check yes for those that apply. (check = Yes 2)

text

CL.11

Code List

If you have had any of the illness listed below, please check yes for those that apply. (check = 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

text

Family History

Item Group

Family History

Brothers

Item

Brothers

text

Sisters

Item

Sisters

text

Sons

Item

Sons

text

Daughters

Item

Daughters

text

PatientAdoptedInd-3

Item

Are you adopted?

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25290 (NCI Thesaurus Property)
C0425382 (UMLS 2011AA Property)

CL.12

Code List

Are you adopted?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

Bloodrelativewithcancer

Item

Blood relative with cancer

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.13

Code List

Blood relative with cancer

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)

TypeofCancer

Item

Type of Cancer

text

CL.14

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

text

CancerPreventionTrialKnowledgeDocumentedInd-2

Item

Have you ever heard of Cancer Prevention Trials?

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.15

Code List

Have you ever heard of Cancer Prevention Trials?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CancerPreventionTrialParticipationScale

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.16

Code List

CL Item

1- Never Would Consider (1)

CL Item

2 (2)

C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)

CL Item

3 (3)

CL Item

4 (4)

CL Item

5 (5)

CL Item

6 (6)

CL Item

7 (7)

CL Item

8 (8)

CL Item

9 (9)

CL Item

10 (10)

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Lung Cancer NCT00096265 Demographic - A5 RTOG Phase III - Multiple Brain Mets Demographic Data Form - version 2 - 2277657v3.0

No Instruction available.

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