ID

9049

Description

Missing Quality of Life Assessment Form (Form 24-MQL) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA56FC-31B5-6351-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA56FC-31B5-6351-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  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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Breast Cancer NCT00659373 Quality of Life - Missing Quality of Life Assessment Form (Form 24-MQL) - 2073685v3.0

English

MISSING QUALITY OF LIFE ASSESSMENT FORM Please submit this form for each missing Quality of Life Form by indicating the reason for missing data. For each scheduled assessment, there should be a QL core and a QL module, and for English-speaking centers only, a QL Supplement Form.

1 forms  
Ccrr Module For Missing Quality Of Life Assessment Form (form 24-mql)
Description

Ccrr Module For Missing Quality Of Life Assessment Form (form 24-mql)

Patient ID Number (Study No.)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth (day)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
*Scheduled Date of Quality of Life Form (day month year)
Description

ScheduledDateofQualityofLifeForm

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25211
UMLS 2011AA Property
C0086960
Center Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Participating Center Name/ Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Form(s) which were not completed at this scheduled assessment (select all that apply by marking ?X? in the box)
Description

Form(s)whichwerenotcompletedatthisscheduledassessment

Data type

text

Reason patient did not complete the Quality of Life Form(s) at this scheduled assessment (please select one)
Description

ReasonpatientdidnotcompletetheQualityofLifeForm(s)atthisscheduledassessment

Data type

text

Other, (specify:)
Description

Other,sourceofsurvivalinformation

Data type

text

Reason patient missed this scheduled clinic appointment: (please select one)
Description

Reasonpatientmissedthisscheduledclinicappointment:

Data type

text

Investigator/Designee Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date (day month year)
Description

InvestigatorSignatureDate

Data type

date

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Similar models

MISSING QUALITY OF LIFE ASSESSMENT FORM Please submit this form for each missing Quality of Life Form by indicating the reason for missing data. For each scheduled assessment, there should be a QL core and a QL module, and for English-speaking centers only, a QL Supplement Form.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Missing Quality Of Life Assessment Form (form 24-mql)
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ScheduledDateofQualityofLifeForm
Item
*Scheduled Date of Quality of Life Form (day month year)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25211 (NCI Thesaurus Property)
C0086960 (UMLS 2011AA Property)
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
MainMemberInstitution/Affiliate
Item
Participating Center Name/ Affiliate
text
Item
Form(s) which were not completed at this scheduled assessment (select all that apply by marking ?X? in the box)
text
CL.1
Code List
Form(s) which were not completed at this scheduled assessment (select all that apply by marking ?X? in the box)
CL Item
Core Form (Core Form)
CL Item
Module Form (Module Form)
C19464 (NCI Thesaurus)
C0376315 (UMLS 2011AA)
C42721 (NCI Thesaurus-3)
C1709061 (UMLS 2011AA-4)
CL Item
Supplement Form (Supplement Form)
Item
Reason patient did not complete the Quality of Life Form(s) at this scheduled assessment (please select one)
text
CL.2
Code List
Reason patient did not complete the Quality of Life Form(s) at this scheduled assessment (please select one)
CL Item
Patient Felt Too Ill To Complete The Quality Of Life Form At This Assessment. (Patient felt too ill to complete the Quality of Life Form at this assessment.)
CL Item
Form Not Presented Or Mailed To Patient. (Form not presented or mailed to patient.)
CL Item
Patient Refused To Participate In Quality Of Life Assessment. (Patient refused to participate in Quality of Life assessment.)
CL Item
Patient Did Not Come To Clinic And Mailed Form Was Not Returned. (Patient did not come to clinic and mailed form was not returned.)
CL Item
Patient Wishes To Withdraw From Further Participation In The Quality Of Life Study. (Patient wishes to withdraw from further participation in the Quality of Life Study.)
CL Item
Other, Specify: (Other, specify:)
Other,sourceofsurvivalinformation
Item
Other, (specify:)
text
Item
Reason patient missed this scheduled clinic appointment: (please select one)
text
CL.3
Code List
Reason patient missed this scheduled clinic appointment: (please select one)
CL Item
Patient On Holiday (Patient on holiday)
CL Item
Patient In Hospital Or Nursing Home (Patient in hospital or nursing home)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
InvestigatorSignature
Item
Investigator/Designee Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
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