ID

8136

Descrição

QF RTOG Phase III-Multiple Brain Mets 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=D7FA4A0B-63F5-6417-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA4A0B-63F5-6417-E034-0003BA12F5E7

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00096265 Quality of Life - QF RTOG Phase III-Multiple Brain Mets - 2277089v3.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: QF RTOG Phase III-Multiple Brain Mets
    1. No Instruction available.
Header
Descrição

Header

[RTOG Study No.]
Descrição

Protocol ID RTOG

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Descrição

Case#

Tipo de dados

text

Institution
Descrição

Institution Name

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Descrição

Institution Number

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Participant's Initials
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participant's I.D. No.
Descrição

Patient Study ID

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Date Form Completed
Descrição

Date Form Completed

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
Module 1
Descrição

Module 1

Mobility (Please circle one statement in each group below which best describes your health today.)
Descrição

QOLMobilityAssessmentStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Metathesaurus Property
C0449580
Self-Care (Please circle one statement in each group below which best describes your health today.)
Descrição

QOLSelf-careStatusType

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Usual Activities (Please circle one statement in each group below which best describes your health today.)
Descrição

QOLPhyscialActivityAssessmentStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C17708
UMLS 2011AA Property-2
C0026606
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Pain/Discomfort (Please circle one statement in each group below which best describes your health today.)
Descrição

QOLPainAssessmentStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3303
UMLS 2011AA Property-2
C0030193
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Anxiety/Depression (Please circle one statement in each group below which best describes your health today.)
Descrição

QOLAnxietyAssessmentStatus

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C26696
UMLS 2011AA Property-2
C0003467
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Module 2
Descrição

Module 2

Date
Descrição

ResponsiblePersonSignatureDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass-2
C25657
UMLS 2011AA ObjectClass-2
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Your own health state today
Descrição

Yourownhealthstatetoday

Tipo de dados

text

Patient's signature
Descrição

Patient'ssignature

Tipo de dados

text

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: QF RTOG Phase III-Multiple Brain Mets
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Header
Item
[RTOG Study No.]
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
CL.1
Code List
[RTOG Study No.]
CL Item
RTOG Study 0320 (RTOG Study 0320)
Case#
Item
Case #
text
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 No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Participant's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient Study ID
Item
Participant's I.D. No.
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Date Form Completed
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Module 1
Item
Mobility (Please circle one statement in each group below which best describes your health today.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0449580 (NCI Metathesaurus Property)
CL.2
Code List
Mobility (Please circle one statement in each group below which best describes your health today.)
CL Item
I Have No Problems In Walking About (I have no problems in walking about)
CL Item
I Have Some Problems In Walking About (I have some problems in walking about)
CL Item
I Am Confined To Bed (I am confined to bed)
Item
Self-Care (Please circle one statement in each group below which best describes your health today.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.3
Code List
Self-Care (Please circle one statement in each group below which best describes your health today.)
CL Item
I Have No Problems With Self-care (I have no problems with self-care)
CL Item
I Have Some Problems Washing Or Dressing Myself (I have some problems washing or dressing myself)
CL Item
I Am Unable To Wash Or Dress Myself (I am unable to wash or dress myself)
Item
Usual Activities (Please circle one statement in each group below which best describes your health today.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C17708 (NCI Thesaurus Property-2)
C0026606 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.4
Code List
Usual Activities (Please circle one statement in each group below which best describes your health today.)
CL Item
I Have No Problems With Performing My Usual Activities (I have no problems with performing my usual activities)
CL Item
I Have Some Problems With Performing My Usual Activities (I have some problems with performing my usual activities)
CL Item
I Am Unable To Perform My Usual Activities (I am unable to perform my usual activities)
Item
Pain/Discomfort (Please circle one statement in each group below which best describes your health today.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3303 (NCI Thesaurus Property-2)
C0030193 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.5
Code List
Pain/Discomfort (Please circle one statement in each group below which best describes your health today.)
CL Item
I Have No Pain Or Discomfort (I have no pain or discomfort)
CL Item
I Have Moderate Pain Or Discomfort (I have moderate pain or discomfort)
CL Item
I Have Extreme Pain Or Discomfort (I have extreme pain or discomfort)
Item
Anxiety/Depression (Please circle one statement in each group below which best describes your health today.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C26696 (NCI Thesaurus Property-2)
C0003467 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.6
Code List
Anxiety/Depression (Please circle one statement in each group below which best describes your health today.)
CL Item
I Am Not Anxious Or Depressed (I am not anxious or depressed)
CL Item
I Am Moderately Anxious Or Depressed (I am moderately anxious or depressed)
CL Item
I Am Extremely Anxious Or Depressed (I am extremely anxious or depressed)
Item Group
Module 2
ResponsiblePersonSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C1273518 (UMLS 2011AA ObjectClass-2)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
Yourownhealthstatetoday
Item
Your own health state today
text
Patient'ssignature
Item
Patient's signature
text
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