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7016

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

Link

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

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/8/15 1/8/15 - Martin Dugas
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January 8, 2015

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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

    English

    No Instruction available.

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

    Header

    NCCTG Protocol Number
    Description

    Protocol ID NCCTG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1518419
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25581
    NCCTG Patient ID
    Description

    PatientNorthCentralCancerTreatmentGroupIdentifierNumber

    Data type

    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-2
    C25581
    UMLS 2011AA Property-2
    C1518419
    Patient Initials (L F M)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution
    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 Number
    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
    Are data amended (If yes, highlight amended areas)
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Time point
    Description

    AssessmentPeriodType

    Data type

    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

    Cycle Number Chemotherapeutics

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property-2
    C25379
    Date Completed
    Description

    FormCompletionDate

    Data type

    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

    Data type

    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

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    C0451019
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C48167
    UMLS 2011AA Property
    C1705822
    NCI Thesaurus Property-3
    C50367
    UMLS 2011AA Property-2
    C0004916
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Grooming
    Description

    BarthelFunctionalIndexGroomingAssessmentIndicator

    Data type

    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

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    C0451019
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C48167
    UMLS 2011AA Property
    C1705822
    NCI Metathesaurus Property
    C0040364
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Bathing
    Description

    BarthelFunctionalIndexBathingAssessmentIndicator

    Data type

    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

    Data type

    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

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus Property
    C25367
    NCI Metathesaurus ObjectClass
    C0451019
    NCI Thesaurus Property-2
    C48960
    UMLS 2011AA Property
    C1710179
    Dressing
    Description

    BarthelFunctionalIndexDressingAssessmentIndicator

    Data type

    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

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    C0451019
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C12736
    UMLS 2011AA Property
    C0021853
    NCI Metathesaurus Property
    CL143501
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Bladder Control
    Description

    BarthelFunctionalIndexBladderControlAssessmentIndicator

    Data type

    text

    Alias
    NCI Metathesaurus ObjectClass
    C0451019
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    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 forms
    1. StudyEvent: North Central Cancer Treatment Group Functional Independence
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Protocol ID NCCTG
    Item
    NCCTG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1518419 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25581 (NCI Thesaurus Property-2)
    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-2)
    C1518419 (UMLS 2011AA Property-2)
    Patient Initials
    Item
    Patient Initials (L F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Name
    Item
    Institution
    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 Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Data amended
    Item
    Are data amended (If yes, highlight amended areas)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    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)
    Cycle Number Chemotherapeutics
    Item
    Current Cycle Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    C25379 (NCI Thesaurus Property-2)
    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-2)
    C1705822 (UMLS 2011AA Property)
    C50367 (NCI Thesaurus Property-3)
    C0004916 (UMLS 2011AA Property-2)
    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-2)
    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-2)
    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-2)
    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-2)
    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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