ID

8759

Beskrivning

Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet 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=D7FA3BB6-3594-636D-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D7FA3BB6-3594-636D-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00096265 Quality of Life - Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet - 2277042v3.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet
    1. No Instruction available.
Header
Beskrivning

Header

[RTOG Study No.]
Beskrivning

Protocol ID RTOG

Datatyp

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 #
Beskrivning

Case#

Datatyp

text

Institution
Beskrivning

Institution Name

Datatyp

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.
Beskrivning

Institution Number

Datatyp

text

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

Patient Name

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1299487
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
Participant's I.D. No.
Beskrivning

Patient Study ID

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Module 1
Beskrivning

Module 1

If this is a revised or corrected form, indicate by checking box.
Beskrivning

Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

Datatyp

text

Module 2
Beskrivning

Module 2

Calendar Due Date
Beskrivning

CalenderDueDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C19459
UMLS 2011AA ObjectClass
C1516147
NCI Thesaurus Property
C45263
UMLS 2011AA Property
C0678226
Was questionnaire completed?
Beskrivning

QualityofLifeCompleteAssessmentInd-2

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property-2
C25367
Date Questionnaire Completed
Beskrivning

QualityofLifeCompleteAssessmentDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property-2
C25367
Other reason, specify
Beskrivning

QOLNotAdministeredSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Type of Quality of Life Form
Beskrivning

TypeofQualityofLifeForm

Datatyp

text

Time point of assessment of protocol treatment
Beskrivning

Timepointofassessmentofprotocoltreatment

Datatyp

text

Other, specify
Beskrivning

Other,specify

Datatyp

text

Did the patient require assistance in completing the radiotherapy questionnaire?
Beskrivning

Didthepatientrequireassistanceincompletingtheradiotherapyquestionnaire?

Datatyp

boolean

Who
Beskrivning

Who

Datatyp

text

Reason
Beskrivning

Reason

Datatyp

text

Reason Questionnaire Was Not Completed
Beskrivning

ReasonQuestionnaireWasNotCompleted

Datatyp

text

Patient refused, specify reason for refusal
Beskrivning

Patientrefused,specifyreasonforrefusal

Datatyp

text

Module 3
Beskrivning

Module 3

Comments
Beskrivning

Research Comments

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Signature of person completing cover page
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Date
Beskrivning

ResponsiblePersonSignatureDate

Datatyp

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
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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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 Name
Item
Participant's Name
text
C25191 (NCI Thesaurus ValueDomain)
C1299487 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (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)
Item Group
Module 1
Ifthisisarevisedorcorrectedform,indicatebycheckingbox.
Item
If this is a revised or corrected form, indicate by checking box.
text
Item Group
Module 2
CalenderDueDate
Item
Calendar Due Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19459 (NCI Thesaurus ObjectClass)
C1516147 (UMLS 2011AA ObjectClass)
C45263 (NCI Thesaurus Property)
C0678226 (UMLS 2011AA Property)
QualityofLifeCompleteAssessmentInd-2
Item
Was questionnaire completed?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
QualityofLifeCompleteAssessmentDate
Item
Date Questionnaire Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
QOLNotAdministeredSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item
Type of Quality of Life Form
text
CL.2
Code List
Type of Quality of Life Form
CL Item
Eq5d (EQ5D)
CL Item
Fact-g (Fact-G)
CL Item
Fact Subscale (Fact Subscale)
Item
Time point of assessment of protocol treatment
text
CL.4
Code List
Time point of assessment of protocol treatment
CL Item
Baseline/pretreatment (Pretreatment)
CL Item
3 Month Follow-up (Three (3) month follow-up)
CL Item
6 Month Follow-up (Six (6) month follow-up)
CL Item
9 Month Follow-up (Nine (9) month follow-up)
CL Item
12 Month Follow-up (Twelve (12) month follow-up)
CL Item
18 Month Follow-up (Eighteen (18) month follow-up)
CL Item
24 Month Follow-up (Twenty-four (24) month follow-up)
CL Item
Other, Specify (Other)
Other,specify
Item
Other, specify
text
Didthepatientrequireassistanceincompletingtheradiotherapyquestionnaire?
Item
Did the patient require assistance in completing the radiotherapy questionnaire?
boolean
Who
Item
Who
text
Reason
Item
Reason
text
Item
Reason Questionnaire Was Not Completed
text
CL.6
Code List
Reason Questionnaire Was Not Completed
CL Item
Not Applicable (Not applicable)
CL Item
Patient Too Ill (Patient was too ill)
CL Item
Patient Unable To Be Contacted (Patient unable to be contacted)
CL Item
Institution Error (Questionnaire not completed due to institutional error)
CL Item
Institution Not Participating In Qol (Institution not participating in QOL)
CL Item
Patient Refused (Patient refused)
CL Item
Other Reason (Other reason)
CL Item
Unknown (Unknown)
Patientrefused,specifyreasonforrefusal
Item
Patient refused, specify reason for refusal
text
Item Group
Module 3
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Responsible Person Signature
Item
Signature of person completing cover page
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
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)
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