Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item
Method of assessment (mark one with an X)
text
Code List
Method of assessment (mark one with an X)
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
CL Item
Telephone Interview (Telephone interview)
CL Item
Mailed Questionnaire (Mailed questionnaire)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
double
Item
Language in which assessment was conducted (mark one with an X)
text
Code List
Language in which assessment was conducted (mark one with an X)
CL Item
English (English)
C43853 (NCI Thesaurus)
C1556083 (UMLS 2011AA)
CL Item
Spanish (Spanish)
CL Item
Other, Specify (Other, specify)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify (language in which assessment was conducted)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Quality of life assessment (mark one with an X)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
Code List
Quality of life assessment (mark one with an X)
CL Item
Completed (Completed)
CL Item
Partially Completed (Partially completed)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
double
Item
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
text
Code List
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
CL Item
Patient Too Medically Ill (Patient too medically ill)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Died (Patient died)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Patient Refuses (Patient refuses)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify (reason assessment was partially completed or not done)
text