ID

6396

Description

North Central Cancer Treatment Group Functional Independence Stereotactic Radiation Therapy With or Without Whole-Brain Radiation Therapy in Treating Patients With Brain Metastases Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=10DD7D18-F9F9-2FC3-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=10DD7D18-F9F9-2FC3-E044-0003BA3F9857

Mots-clés

Versions (2)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 08/01/2015 08/01/2015 - Martin Dugas
Téléchargé le

18 décembre 2014

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00377156 Pre-Study - North Central Cancer Treatment Group Functional Independence - 2470805v1.0

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: North Central Cancer Treatment Group Functional Independence
    1. No Instruction available.
Header
Description

Header

NCCTG Protocol Number
Description

ProtocolNorthCentralCancerTreatmentGroupIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25581
UMLS 2011AA Property
C1518419
NCCTG Patient ID
Description

PatientNorthCentralCancerTreatmentGroupIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25581
UMLS 2011AA Property
C1518419
Patient Initials (L F M)
Description

PatientInitialsName

Type de données

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
Institution
Description

InstitutionName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution Number
Description

InstitutionIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Are data amended (If yes, highlight amended areas)
Description

DataAmendedInd-3

Type de données

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Time point
Description

AssessmentPeriodType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
Current Cycle Number
Description

TreatmentCurrentCourseNumber

Type de données

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25379
UMLS 2011AA Property
C0750729
Date Completed
Description

FormCompletionDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
Barthel Function Index
Description

Barthel Function Index

Feeding
Description

BarthelFunctionalIndexFeedingAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus ObjectClass
C0451019
MGED Property
X-MO-5488
Chair/bed transfers
Description

BarthelFunctionalIndexBedTransferAssessmentIndicator

Type de données

text

Alias
NCI Metathesaurus ObjectClass
C0451019
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C48167
UMLS 2011AA Property
C1705822
NCI Thesaurus Property
C50367
UMLS 2011AA Property
C0004916
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Grooming
Description

BarthelFunctionalIndexGroomingAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus ObjectClass
C0451019
NCI Metathesaurus Property
CL306660
Toilet Transfers
Description

BarthelFunctionalIndexToiletTransferAssessmentIndicator

Type de données

text

Alias
NCI Metathesaurus ObjectClass
C0451019
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C48167
UMLS 2011AA Property
C1705822
NCI Metathesaurus Property
C0040364
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Bathing
Description

BarthelFunctionalIndexBathingAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus Property
C0150141
NCI Metathesaurus ObjectClass
C0451019
Walking
Description

BarthelFunctionalIndexWalkingAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus Property
C0080331
NCI Metathesaurus ObjectClass
C0451019
Stairs
Description

BarthelFunctionalIndexStairsAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus ObjectClass
C0451019
NCI Thesaurus Property
C48960
UMLS 2011AA Property
C1710179
Dressing
Description

BarthelFunctionalIndexDressingAssessmentIndicator

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25367
NCI Metathesaurus Property
CL313791
NCI Metathesaurus ObjectClass
C0451019
Bowel Control
Description

BarthelFunctionalIndexBowelControlAssessmentIndicator

Type de données

text

Alias
NCI Metathesaurus ObjectClass
C0451019
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C12736
UMLS 2011AA Property
C0021853
NCI Metathesaurus Property
CL143501
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Bladder Control
Description

BarthelFunctionalIndexBladderControlAssessmentIndicator

Type de données

text

Alias
NCI Metathesaurus ObjectClass
C0451019
NCI Thesaurus Property
C25367
NCI Thesaurus Property
C12414
UMLS 2011AA Property
C0005682
NCI Metathesaurus Property
CL143501
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: North Central Cancer Treatment Group Functional Independence
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header
ProtocolNorthCentralCancerTreatmentGroupIdentifierNumber
Item
NCCTG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25581 (NCI Thesaurus Property)
C1518419 (UMLS 2011AA Property)
PatientNorthCentralCancerTreatmentGroupIdentifierNumber
Item
NCCTG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25581 (NCI Thesaurus Property)
C1518419 (UMLS 2011AA Property)
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)
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 Number
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)
Item
Are data amended (If yes, highlight amended areas)
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)
CL.1
Code List
Are data amended (If yes, highlight amended areas)
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.2
Code List
Time point
CL Item
Baseline (baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
TreatmentCurrentCourseNumber
Item
Current Cycle Number
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C0750729 (UMLS 2011AA Property)
FormCompletionDate
Item
Date Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Item Group
Barthel Function Index
Item
Feeding
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
X-MO-5488 (MGED Property)
CL.3
Code List
Feeding
CL Item
Independent. Able To Put On Any Assistance Device. Eats In Reasonable Time. (Independent. Able to put on any assistance device. Eats in reasonable time.)
CL Item
Needs Help, E.g., For Cutting Food. (Needs Help, e.g., for cutting food.)
CL Item
Dependent (Dependent)
Item
Chair/bed transfers
text
C0451019 (NCI Metathesaurus ObjectClass)
C25367 (NCI Thesaurus Property)
C48167 (NCI Thesaurus Property)
C1705822 (UMLS 2011AA Property)
C50367 (NCI Thesaurus Property)
C0004916 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
Chair/bed transfers
CL Item
Independent. Can Lock A Wheelchair, Lift Footrests, And Get Out. (Independent. Can lock a wheelchair, lift footrests, and get out.)
CL Item
Minimum Assistance Or Supervision. (Minimum assistance or supervision.)
CL Item
Able To Sit, But Need Maximum Assistance To Transfer. (Able to sit, but need maximum assistance to transfer.)
CL Item
Dependent (Dependent)
Item
Grooming
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
CL306660 (NCI Metathesaurus Property)
CL.5
Code List
Grooming
CL Item
Independent. Can Wash Face, Comb Hair, Brush Teeth, Shave (can Manage Plug In Electric Razor). (Independent. Can wash face, comb hair, brush teeth, shave (can manage plug in electric razor).)
CL Item
Needs Help With Grooming. (Needs help with grooming.)
Item
Toilet Transfers
text
C0451019 (NCI Metathesaurus ObjectClass)
C25367 (NCI Thesaurus Property)
C48167 (NCI Thesaurus Property)
C1705822 (UMLS 2011AA Property)
C0040364 (NCI Metathesaurus Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.6
Code List
Toilet Transfers
CL Item
Independent. Can Get On And Off, Handle Clothes, Or Toilet Paper. (Independent. Can get on and off, handle clothes, or toilet paper.)
CL Item
Needs Help For Balance, Handling Clothes, Or Toilet Paper. (Needs help for balance, handling clothes, or toilet paper.)
CL Item
Dependent (Dependent)
Item
Bathing
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C0150141 (NCI Metathesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
CL.7
Code List
Bathing
CL Item
Independent. Able To Use Bath Tub, Shower, Or Take Complete Sponge Bath Without Supervision. (Independent. Able to use bath tub, shower, or take complete sponge bath without supervision.)
CL Item
Dependent (Dependent)
Item
Walking
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C0080331 (NCI Metathesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
CL.8
Code List
Walking
CL Item
Independent To 50 Yards. May Use Assistive Devices. (Independent to 50 yards. May use assistive devices.)
CL Item
Can Walk With Help For 50 Yards. (Can walk with help for 50 yards.)
CL Item
Unable To Walk, But Independent In Wheelchair For 50 Yards. (Unable to walk, but independent in wheelchair for 50 yards.)
CL Item
Dependent (Dependent)
Item
Stairs
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
C48960 (NCI Thesaurus Property)
C1710179 (UMLS 2011AA Property)
CL.9
Code List
Stairs
CL Item
Independent Up And Down. May Use Assistive Devices. (Independent up and down. May use assistive devices.)
CL Item
Needs Help Or Supervision. (Needs help or supervision.)
CL Item
Unable (Unable)
Item
Dressing
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus Property)
CL313791 (NCI Metathesaurus Property)
C0451019 (NCI Metathesaurus ObjectClass)
CL.10
Code List
Dressing
CL Item
Independent. Can Tie Shoes, Fasten Fasteners, Undress. (Independent. Can tie shoes, fasten fasteners, undress.)
CL Item
Needs Help But Does At Least Half Of Task Within Reasonable Time. (Needs help but does at least half of task within reasonable time.)
CL Item
Dependent (Dependent)
Item
Bowel Control
text
C0451019 (NCI Metathesaurus ObjectClass)
C25367 (NCI Thesaurus Property)
C12736 (NCI Thesaurus Property)
C0021853 (UMLS 2011AA Property)
CL143501 (NCI Metathesaurus Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.11
Code List
Bowel Control
CL Item
No Accidents. Able To Use Enema Or Suppository, If Needed. (No accidents. Able to use enema or suppository, if needed.)
CL Item
Occasional Accidents (<1/week) Or Need Help With External Device. (Occasional accidents (<1/week) or need help with external device.)
CL Item
Incontinent (Incontinent)
Item
Bladder Control
text
C0451019 (NCI Metathesaurus ObjectClass)
C25367 (NCI Thesaurus Property)
C12414 (NCI Thesaurus Property)
C0005682 (UMLS 2011AA Property)
CL143501 (NCI Metathesaurus Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.12
Code List
Bladder Control
CL Item
No Accidents. Able To Care For Collecting Device, If Used. (No accidents. Able to care for collecting device, if used.)
CL Item
Occasional Accidents (<1/day) Or Need Help With External Device. (Occasional accidents (<1/day) or need help with external device.)
CL Item
Incontinent (Incontinent)
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