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7058

Description

PACCT-1 TAILORx Assessment Compliance Form Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7D4C-582E-E040-BB89AD436C2E

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7D4C-582E-E040-BB89AD436C2E

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  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 NCT00310180 Quality of Life - PACCT-1 TAILORx Assessment Compliance Form - 3071476v1.0

    English

    INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

    1 forms  
    Header
    Description

    Header

    ECOG Protocol Number
    Description

    Protocol Number ECOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    ECOG Patient ID
    Description

    Patient ID ECOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    DCI Name
    Description

    Generic drug form

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C3242750
    NCI Thesaurus Property
    C19464
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus ObjectClass-2
    C25452
    Report Period
    Description

    Cycle number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25214
    NCI Thesaurus Property-2
    C25616
    NCI Thesaurus ObjectClass
    C15368
    Unnamed2
    Description

    Unnamed2

    Are data amended
    Description

    Data amended

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Date data amended (s M D Y)
    Description

    Data amended date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property
    C25416
    NCI Thesaurus ValueDomain-2
    C25367
    Date data amended (s M D Y)
    Description

    Data amended date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property
    C25416
    NCI Thesaurus ValueDomain-2
    C25367
    E2906 Qol Assessment Not Completed
    Description

    E2906 Qol Assessment Not Completed

    Assessment date (M D Y)
    Description

    Assessment Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2985720
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C38000
    Section Ii - E1a05 Qol Assessment Not Completed
    Description

    Section Ii - E1a05 Qol Assessment Not Completed

    Were all the quality of life forms completed for this timepoint
    Description

    AssessmentFormCompletedInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass-2
    C25367
    Section Ii - Assessments Not Completed
    Description

    Section Ii - Assessments Not Completed

    Patient refusal
    Description

    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C49161
    UMLS 2011AA Property-3
    C1705116
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Unable to accomodate disability or language needs
    Description

    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability or language
    Description

    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C21007
    UMLS 2011AA Property-3
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Patient did not show up in clinic/office
    Description

    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason patient did not show up
    Description

    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C48190
    UMLS 2011AA Property-3
    C0332197
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff unavailable
    Description

    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25429
    UMLS 2011AA Property-3
    C0470187
    NCI Metathesaurus Property
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient not given form by staff
    Description

    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C25594
    UMLS 2011AA Property-3
    C1518422
    NCI Thesaurus Property-4
    C25382
    UMLS 2011AA Property-4
    C1521801
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient too ill
    Description

    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient expired
    Description

    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus Property-3
    C28554
    UMLS 2011AA Property-3
    C0011065
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Assessment not required per protocol
    Description

    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify reason assessment is not required
    Description

    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C25594
    UMLS 2011AA Property-2
    C1518422
    NCI Thesaurus Property-3
    C25652
    UMLS 2011AA Property-3
    C1514873
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Staff thought patient too ill
    Description

    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Metathesaurus Property
    C0221423
    NCI Metathesaurus Property-2
    C0025106
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Description

    Quality-of-LifeAssessmentOtherIncompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Description

    Quality-of-LifeAssessmentOtherIncompleteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C49160
    UMLS 2011AA Property-2
    C0205257
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Section Iii Assessment Completed
    Description

    Section Iii Assessment Completed

    Was Assessment self-administered?
    Description

    AssessmentSelf-AdministeredInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25217
    UMLS 2011AA ObjectClass
    C1516048
    NCI Thesaurus Property
    C25670
    UMLS 2011AA Property
    C1519231
    How Was The Patient Assisted
    Description

    How Was The Patient Assisted

    Were the questions read aloud to patient
    Description

    Quality-of-LifeAssessmentSpeechAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C38025
    UMLS 2011AA Property
    C0037817
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Did the patient require clarification of questions or instructions
    Description

    Quality-of-LifeAssessmentDefinitionAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C42777
    UMLS 2011AA Property
    C1704788
    Did the patient require other assistance
    Description

    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C25652
    UMLS 2011AA Property-2
    C1514873
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Were the forms completed independently by another person
    Description

    Quality-of-LifeAssessmentOtherPersonCompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25190
    UMLS 2011AA Property-2
    C0027361
    NCI Thesaurus Property-3
    C25250
    UMLS 2011AA Property-3
    C0205197
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    What Was The Reason For Assistance
    Description

    What Was The Reason For Assistance

    Did the patient have a language difficulty (questions needed to tbe translated)
    Description

    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify language
    Description

    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C28020
    UMLS 2011AA Property
    C0033213
    NCI Thesaurus Property-2
    C16779
    UMLS 2011AA Property-2
    C0023008
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Did the patient have a literacy difficulty (patient could not read well enough)
    Description

    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C28020
    UMLS 2011AA Property-2
    C0033213
    NCI Thesaurus Property-3
    C49162
    UMLS 2011AA Property-3
    C0023864
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Was the patient disabled
    Description

    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify disability
    Description

    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property-2
    C21007
    UMLS 2011AA Property-2
    C0231170
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Were the forms completed via a telephone interview
    Description

    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    NCI Thesaurus Property-2
    C16751
    UMLS 2011AA Property-2
    C0021822
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Description

    Quality-of-LifeAssessmentOtherAssistanceInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other reason
    Description

    Quality-of-LifeAssessmentOtherAssistanceSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Metathesaurus Property
    C0018896
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Description

    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?

    Staff
    Description

    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Metathesaurus Property
    C0025106
    Family
    Description

    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus Property-3
    C41256
    UMLS 2011AA Property-3
    C0086282
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Friend
    Description

    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    NCI Thesaurus Property
    C16960
    UMLS 2011AA Property
    C0030705
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Metathesaurus Property
    C0079382
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other
    Description

    Quality-of-LifeAssessmentOtherCompleteInd-2

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Specify other person
    Description

    Quality-of-LifeAssessmentOtherCompleteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25250
    UMLS 2011AA Property-2
    C0205197
    NCI Thesaurus ObjectClass
    C15584
    UMLS 2011AA ObjectClass
    C0281588
    Comments
    Description

    Comments

    Investigator Signature
    Description

    Investigator Signature

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    NCI Thesaurus ObjectClass
    C17089
    Investigator Signature Date (M D Y)
    Description

    Investigator Signature Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    UMLS CUI-2
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C17089
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    INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Protocol Number ECOG
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Patient ID ECOG
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Generic drug form
    Item
    DCI Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C3242750 (UMLS CUI-1)
    C19464 (NCI Thesaurus Property)
    C25474 (NCI Thesaurus ObjectClass)
    C25452 (NCI Thesaurus ObjectClass-2)
    Item
    Report Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25214 (NCI Thesaurus Property)
    C25616 (NCI Thesaurus Property-2)
    C15368 (NCI Thesaurus ObjectClass)
    CL.1
    Code List
    Report Period
    CL Item
    Baseline (baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    C25213 (NCI Thesaurus-3)
    C1442488 (UMLS 2011AA-4)
    CL Item
    3 Months (3 months)
    CL Item
    6 Months (6 months)
    CL Item
    12 Months (12 months)
    CL Item
    24 Months (24 months)
    CL Item
    36 Months (36 months)
    Item Group
    Unnamed2
    Data amended
    Item
    Are data amended
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Data amended date
    Item
    Date data amended (s M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
    Data amended date
    Item
    Date data amended (s M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item Group
    E2906 Qol Assessment Not Completed
    Assessment Date
    Item
    Assessment date (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2985720 (UMLS CUI-1)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C38000 (NCI Thesaurus Property)
    Item Group
    Section Ii - E1a05 Qol Assessment Not Completed
    AssessmentFormCompletedInd-2
    Item
    Were all the quality of life forms completed for this timepoint
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ObjectClass-2)
    Item Group
    Section Ii - Assessments Not Completed
    Quality-of-LifeAssessmentPatientRefuseIncompleteInd-2
    Item
    Patient refusal
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C49161 (NCI Thesaurus Property-3)
    C1705116 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteInd-2
    Item
    Unable to accomodate disability or language needs
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityIncompleteSpecify
    Item
    Specify disability or language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C21007 (NCI Thesaurus Property-3)
    C0231170 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteInd-2
    Item
    Patient did not show up in clinic/office
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientAbsentIncompleteSpecify
    Item
    Specify reason patient did not show up
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C48190 (NCI Thesaurus Property-3)
    C0332197 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffUnavailableIncompleteInd-2
    Item
    Staff unavailable
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25429 (NCI Thesaurus Property-3)
    C0470187 (UMLS 2011AA Property-3)
    C0025106 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientNotAdministeredIncompleteInd-2
    Item
    Patient not given form by staff
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C25594 (NCI Thesaurus Property-3)
    C1518422 (UMLS 2011AA Property-3)
    C25382 (NCI Thesaurus Property-4)
    C1521801 (UMLS 2011AA Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientSicknessIncompleteInd-2
    Item
    Patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDeathIncompleteInd-2
    Item
    Patient expired
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C28554 (NCI Thesaurus Property-3)
    C0011065 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteInd-2
    Item
    Assessment not required per protocol
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentNotRequiredIncompleteSpecify
    Item
    Specify reason assessment is not required
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C25594 (NCI Thesaurus Property-2)
    C1518422 (UMLS 2011AA Property-2)
    C25652 (NCI Thesaurus Property-3)
    C1514873 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentMedicalStaffPatientSicknessIncompleteInd-2
    Item
    Staff thought patient too ill
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C0221423 (NCI Metathesaurus Property)
    C0025106 (NCI Metathesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherIncompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherIncompleteSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C49160 (NCI Thesaurus Property-2)
    C0205257 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Section Iii Assessment Completed
    AssessmentSelf-AdministeredInd-2
    Item
    Was Assessment self-administered?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25217 (NCI Thesaurus ObjectClass)
    C1516048 (UMLS 2011AA ObjectClass)
    C25670 (NCI Thesaurus Property)
    C1519231 (UMLS 2011AA Property)
    Item Group
    How Was The Patient Assisted
    Quality-of-LifeAssessmentSpeechAssistanceInd-2
    Item
    Were the questions read aloud to patient
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C38025 (NCI Thesaurus Property)
    C0037817 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentDefinitionAssistanceInd-2
    Item
    Did the patient require clarification of questions or instructions
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C42777 (NCI Thesaurus Property)
    C1704788 (UMLS 2011AA Property)
    Quality-of-LifeAssessmentOtherRequiredAssistanceInd-2
    Item
    Did the patient require other assistance
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C25652 (NCI Thesaurus Property-2)
    C1514873 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherPersonCompleteInd-2
    Item
    Were the forms completed independently by another person
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25190 (NCI Thesaurus Property-2)
    C0027361 (UMLS 2011AA Property-2)
    C25250 (NCI Thesaurus Property-3)
    C0205197 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Item Group
    What Was The Reason For Assistance
    Quality-of-LifeAssessmentLanguageProblemAssistanceInd-2
    Item
    Did the patient have a language difficulty (questions needed to tbe translated)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentLanguageProblemAssistanceSpecify
    Item
    Specify language
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property)
    C0033213 (UMLS 2011AA Property)
    C16779 (NCI Thesaurus Property-2)
    C0023008 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientLiteracyProblemAssistanceInd-2
    Item
    Did the patient have a literacy difficulty (patient could not read well enough)
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C28020 (NCI Thesaurus Property-2)
    C0033213 (UMLS 2011AA Property-2)
    C49162 (NCI Thesaurus Property-3)
    C0023864 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceInd-2
    Item
    Was the patient disabled
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientDisabilityAssistanceSpecify
    Item
    Specify disability
    text
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C21007 (NCI Thesaurus Property-2)
    C0231170 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentTelephoneInterviewAssistanceInd-2
    Item
    Were the forms completed via a telephone interview
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0018896 (NCI Metathesaurus Property)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    C16751 (NCI Thesaurus Property-2)
    C0021822 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherAssistanceInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherAssistanceSpecify
    Item
    Specify other reason
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C0018896 (NCI Metathesaurus Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?
    Quality-of-LifeAssessmentMedicalStaffCompleteInd-2
    Item
    Staff
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C0025106 (NCI Metathesaurus Property)
    Quality-of-LifeAssessmentPatientFamilyMemberCompleteInd-2
    Item
    Family
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C41256 (NCI Thesaurus Property-3)
    C0086282 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentPatientFriendsCompleteInd-2
    Item
    Friend
    boolean
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    C16960 (NCI Thesaurus Property)
    C0030705 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C0079382 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Quality-of-LifeAssessmentOtherCompleteInd-2
    Item
    Other
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Quality-of-LifeAssessmentOtherCompleteSpecify
    Item
    Specify other person
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property-2)
    C0205197 (UMLS 2011AA Property-2)
    C15584 (NCI Thesaurus ObjectClass)
    C0281588 (UMLS 2011AA ObjectClass)
    Item Group
    Comments
    Investigator Signature
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    Investigator Signature Date
    Item
    Investigator Signature Date (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25367 (NCI Thesaurus ValueDomain-2)
    C17089 (NCI Thesaurus ObjectClass)
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