ID

8173

Description

RTOG 1016 QP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Miscellaneous Patient Assessment Form Radiation Therapy With Cisplatin or Cetuximab in Treating Patients With Oropharyngeal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=94CE2BCD-7B3B-56A6-E040-BB89AD431367

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=94CE2BCD-7B3B-56A6-E040-BB89AD431367

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT01302834 Quality of Life - RTOG 1016 QP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Miscellaneous Patient Assessment Form - 3158700v1.0

English

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms  
  1. StudyEvent: RTOG 1016 QP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Miscellaneous Patient Assessment Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

Protocol ID RTOG

Data type

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 #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
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 No.
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
Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Description

Trial subject ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Unamed Module 2
Description

Unamed Module 2

SCHEDULED DATA POINT (CHECK ONE)
Description

DataAssessmentTimePeriodType

Data type

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
other followup (specify calendar date or followup interval, e.g., 3 months, 2 years, etc.)
Description

DataAssessmentTimePeriodUnspecifiedText

Data type

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Other, specify
Description

DataAssessmentTimePeriodOtherText

Data type

text

Alias
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus ObjectClass-2
C25474
UMLS 2011AA ObjectClass-2
C1511726
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25207
UMLS 2011AA Property-2
C0040223
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
Description

AssessmentNotPerformedReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C49487
UMLS 2011AA Property
C1298908
NCI Thesaurus ObjectClass
C25217
UMLS 2011AA ObjectClass
C1516048
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
Patient refused, including attempts by telephone interview, specify reason for refusal
Description

PatientTelephoneAssessmentRefusaltoParticipateReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
Patient refused, telephone interview not attempted, specify reason for refusal
Description

PatientAssessmentRefusaltoParticipateReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Other reason, specify
Description

OtherPatientAssessmentRefusaltoParticipateReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C17649
UMLS 2011AA ObjectClass
C0205394
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass-2
C16960
UMLS 2011AA ObjectClass-2
C0030705
NCI Thesaurus Property
C25367
WAS INFORMATION OBTAINED BY TELEPHONE INTERVIEW (CHECK ONE)
Description

PatientTelephoneAssessmentInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
Date of Evaluation
Description

LesionAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain-2
C25367
RATER'S NAME
Description

PatientTelephoneAssessmentInterviewersName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C25395
UMLS 2011AA Property-2
C0039457
Normalcy of Diet Rating (CHECK ONE)
Description

DietPerformanceStatusAssessmentIntakeScale

Data type

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25538
UMLS 2011AA ValueDomain-2
C1512806
Public Eating Rating (CHECK ONE)
Description

DietaryPerformanceStatusAssessmentLocationScale

Data type

text

Alias
NCI Metathesaurus ObjectClass
CL092952
NCI Thesaurus ObjectClass
C15222
UMLS 2011AA ObjectClass
C0012155
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C25341
UMLS 2011AA ValueDomain-2
C0450429
Understandability of Speech Rating (CHECK ONE)
Description

SpeechPerformanceStatusAssessmentComprehensionScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C38025
UMLS 2011AA ObjectClass
C0037817
NCI Metathesaurus ObjectClass
CL092952
Comments
Description

Comments

COMMENTS
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Completed by
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date Form Originally Completed (MM DD YYYY)
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
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Similar models

This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

1 forms
  1. StudyEvent: RTOG 1016 QP: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Miscellaneous Patient Assessment Form
    1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
Protocol ID RTOG
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)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Institution Name
Item
Institution Name
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
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Unamed Module 2
Item
SCHEDULED DATA POINT (CHECK ONE)
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.1
Code List
SCHEDULED DATA POINT (CHECK ONE)
CL Item
Pre Treatment Assessment (Pre treatment assessment)
CL Item
Other Followup (other followup)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
DataAssessmentTimePeriodUnspecifiedText
Item
other followup (specify calendar date or followup interval, e.g., 3 months, 2 years, etc.)
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
DataAssessmentTimePeriodOtherText
Item
Other, specify
text
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25474 (NCI Thesaurus ObjectClass-2)
C1511726 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property-2)
C0040223 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
Item
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C49487 (NCI Thesaurus Property)
C1298908 (UMLS 2011AA Property)
C25217 (NCI Thesaurus ObjectClass)
C1516048 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
CL.2
Code List
IF NO PATIENT ASSESSMENT, SPECIFY REASON (CHECK ONE)
CL Item
Patient Was Too Ill (Patient was too ill)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Questionnaire Not Completed Due To Institutional Error (Questionnaire not completed due to institutional error)
CL Item
Patient Refused, Including Attempts By Telephone Interview (Patient refused, including attempts by telephone interview)
CL Item
Patient Refused, Telephone Interview Not Attempted (Patient refused, telephone interview not attempted)
CL Item
Other Reason (Other reason)
PatientTelephoneAssessmentRefusaltoParticipateReason
Item
Patient refused, including attempts by telephone interview, specify reason for refusal
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
PatientAssessmentRefusaltoParticipateReason
Item
Patient refused, telephone interview not attempted, specify reason for refusal
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
OtherPatientAssessmentRefusaltoParticipateReason
Item
Other reason, specify
text
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass-2)
C0030705 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
PatientTelephoneAssessmentInd-2
Item
WAS INFORMATION OBTAINED BY TELEPHONE INTERVIEW (CHECK ONE)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
LesionAssessmentDate
Item
Date of Evaluation
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain-2)
PatientTelephoneAssessmentInterviewersName
Item
RATER'S NAME
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25395 (NCI Thesaurus Property-2)
C0039457 (UMLS 2011AA Property-2)
Item
Normalcy of Diet Rating (CHECK ONE)
text
CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25538 (NCI Thesaurus ValueDomain-2)
C1512806 (UMLS 2011AA ValueDomain-2)
CL.4
Code List
Normalcy of Diet Rating (CHECK ONE)
CL Item
100= Full Diet (no Restrictions) (100)
CL Item
90= Full Diet (liquid Assist) (90)
CL Item
80= All Meat (80)
CL Item
70= Raw Carrots, Celery (70)
CL Item
60= Dry Bread And Crackers (60)
CL Item
50= Soft, Chewable Foods (e.g., Macaroni, Canned/soft Fruits, Cooked Vegetables, Fish, Hamburger, Small Pieces Of Meat) (50)
CL Item
40= Soft Foods Requiring No Chewing (e.g., Mashed Potatoes, Apple Sauce, Pudding) (40)
CL Item
30= Pureed Foods (in Blender) (30)
CL Item
20= Warm Liquids (20)
CL Item
10= Cold Liquids (10)
CL Item
0= Non-oral Feeding (tube Fed) (0)
Item
Public Eating Rating (CHECK ONE)
text
CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus ValueDomain-2)
C0450429 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Public Eating Rating (CHECK ONE)
CL Item
100= No Restriction Of Place, Food Or Companion (eats Out At Any Opportunity) (100)
CL Item
75= No Restriction Of Place, But Restricts Diet When In Public (eats Anywhere, But May Limit Intake To Less "messy" Foods, E.g., Liquids) (75)
CL Item
50= Eats Only In Presence Of Selected Persons In Selected Places (50)
CL Item
25= Eats Only At Home In Presence Of Selected Persons (25)
CL Item
0= Always Eats Alone (0)
Item
Understandability of Speech Rating (CHECK ONE)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C38025 (NCI Thesaurus ObjectClass)
C0037817 (UMLS 2011AA ObjectClass)
CL092952 (NCI Metathesaurus ObjectClass)
CL.6
Code List
Understandability of Speech Rating (CHECK ONE)
CL Item
100= Always Understandable (100)
CL Item
75= Understandable Most Of The Time; Occasional Repetition Necessary (75)
CL Item
50= Usually Understandable; Face-to-face Contact Necessary (50)
CL Item
25= Difficult To Understand (25)
CL Item
0= Never Understandable; May Use Written Communication (0)
Item Group
Comments
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form
Item
Completed by
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Form Completion Date
Item
Date Form Originally Completed (MM DD YYYY)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
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