ID

8199

Description

RTOG 1016 FM: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Work Status Questionnaire Follow-Up Survey 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=9F2D8F51-F2B1-6515-E040-BB89AD434E1D

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9F2D8F51-F2B1-6515-E040-BB89AD434E1D

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 FM: Radiation Therapy Oncology Group Phase III Head and Neck Cancer Work Status Questionnaire Follow-Up Survey - 3209056v1.0

English

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms  
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
Amended data
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Follow-up Survey
Description

Follow-up Survey

Which of the following best describes your current work status
Description

CurrentEmploymentDescriptionStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C25172
UMLS 2011AA ObjectClass-2
C0014003
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Please specify (Other)
Description

CurrentEmploymentDescriptionSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C25172
UMLS 2011AA ObjectClass-2
C0014003
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
How many hours per week are you currently working
Description

EmploymentWeekHourCount

Data type

float

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25529
UMLS 2011AA Property
C0439227
NCI Thesaurus Property-2
C29844
UMLS 2011AA Property-2
C0439230
NCI Thesaurus ObjectClass
C25172
UMLS 2011AA ObjectClass
C0014003
Since the last time of the last survey about how many days were you absent from work for at least half of the day
Description

PatientEmploymentAbsentDayCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property-2
C25172
UMLS 2011AA Property-2
C0014003
NCI Thesaurus ValueDomain
C25301
UMLS 2011AA ValueDomain
C0439228
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Would you say your employer has been good at accommodating your illness and need for treatment (If you are not currently working, please tell us about your last employer)
Description

EmployerFlexibleStatus

Data type

text

Alias
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus ObjectClass
C54144
UMLS 2011AA ObjectClass
C1274022
NCI Thesaurus Property
C80495
UMLS 2011AA Property
C0443220
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Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 forms
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)
Data amended
Item
Amended data
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Follow-up Survey
Item
Which of the following best describes your current work status
text
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C25172 (NCI Thesaurus ObjectClass-2)
C0014003 (UMLS 2011AA ObjectClass-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.2
Code List
Which of the following best describes your current work status
CL Item
Not Working Outside Of The Home (Not working outside of the home)
CL Item
Student, Full-time (Student, full-time)
CL Item
Student, Part-time (Student, part-time)
CL Item
Currently Working In At Least One Full Time Job (Currently working in at least one FULL time job)
CL Item
Currently Working In At Least One Part Time Job (Currently working in at least one PART time job)
CL Item
On Sick Leave (On sick leave)
CL Item
On Disability (On disability)
CL Item
Retired (Retired)
CL Item
Not Employed (Not employed)
CL Item
Other (Other)
CL Item
Unknown (Don't know)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CurrentEmploymentDescriptionSpecify
Item
Please specify (Other)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C25172 (NCI Thesaurus ObjectClass-2)
C0014003 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
EmploymentWeekHourCount
Item
How many hours per week are you currently working
float
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25529 (NCI Thesaurus Property)
C0439227 (UMLS 2011AA Property)
C29844 (NCI Thesaurus Property-2)
C0439230 (UMLS 2011AA Property-2)
C25172 (NCI Thesaurus ObjectClass)
C0014003 (UMLS 2011AA ObjectClass)
PatientEmploymentAbsentDayCount
Item
Since the last time of the last survey about how many days were you absent from work for at least half of the day
float
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25172 (NCI Thesaurus Property-2)
C0014003 (UMLS 2011AA Property-2)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Would you say your employer has been good at accommodating your illness and need for treatment (If you are not currently working, please tell us about your last employer)
text
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C54144 (NCI Thesaurus ObjectClass)
C1274022 (UMLS 2011AA ObjectClass)
C80495 (NCI Thesaurus Property)
C0443220 (UMLS 2011AA Property)
CL.3
Code List
Would you say your employer has been good at accommodating your illness and need for treatment (If you are not currently working, please tell us about your last employer)
CL Item
Strongly Agree (Strongly agree)
CL Item
Agree (Agree)
CL Item
Disagree (Disagree)
CL Item
Strongly Disagree (Strongly disagree)
CL Item
Not Applicable (Not Applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Refused (Refused)
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