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ID

8759

Beschrijving

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

Link

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

Trefwoorden

  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

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

    No Instruction available.

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

    Header

    [RTOG Study No.]
    Beschrijving

    Protocol ID RTOG

    Datatype

    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 #
    Beschrijving

    Case#

    Datatype

    text

    Institution
    Beschrijving

    Institution Name

    Datatype

    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.
    Beschrijving

    Institution Number

    Datatype

    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
    Beschrijving

    Patient Name

    Datatype

    text

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

    Patient Study ID

    Datatype

    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
    Beschrijving

    Module 1

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

    Ifthisisarevisedorcorrectedform,indicatebycheckingbox.

    Datatype

    text

    Module 2
    Beschrijving

    Module 2

    Calendar Due Date
    Beschrijving

    CalenderDueDate

    Datatype

    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?
    Beschrijving

    QualityofLifeCompleteAssessmentInd-2

    Datatype

    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
    Beschrijving

    QualityofLifeCompleteAssessmentDate

    Datatype

    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
    Beschrijving

    QOLNotAdministeredSpecify

    Datatype

    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
    Beschrijving

    TypeofQualityofLifeForm

    Datatype

    text

    Time point of assessment of protocol treatment
    Beschrijving

    Timepointofassessmentofprotocoltreatment

    Datatype

    text

    Other, specify
    Beschrijving

    Other,specify

    Datatype

    text

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

    Didthepatientrequireassistanceincompletingtheradiotherapyquestionnaire?

    Datatype

    boolean

    Who
    Beschrijving

    Who

    Datatype

    text

    Reason
    Beschrijving

    Reason

    Datatype

    text

    Reason Questionnaire Was Not Completed
    Beschrijving

    ReasonQuestionnaireWasNotCompleted

    Datatype

    text

    Patient refused, specify reason for refusal
    Beschrijving

    Patientrefused,specifyreasonforrefusal

    Datatype

    text

    Module 3
    Beschrijving

    Module 3

    Comments
    Beschrijving

    Research Comments

    Datatype

    text

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

    Responsible Person Signature

    Datatype

    text

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

    ResponsiblePersonSignatureDate

    Datatype

    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

    Similar models

    No Instruction available.

    1. StudyEvent: Cover Sheet RTOG Phase III-Multiple Brain Mets Quality of Life Cover Sheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    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)
    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
    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
    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
    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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