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  1. StudyEvent: RTOG-0522 QP: Miscellaneous Patient Assessment Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
RTOG clinical trial administrative data
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
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
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)
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
Miscellaneous Patient Assessment
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)
Code List
SCHEDULED DATA POINT (CHECK ONE)
CL Item
Pre Treatment Assessment (Pre treatment assessment)
CL Item
At Completion Of Radiotherapy (At completion of radiotherapy)
CL Item
Other Followup (other followup)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
DataAssessmentTimePeriodUnspecifiedText
Item
other followup
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)
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
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)
Code List
Normalcy of Diet Rating
CL Item
0= Non-oral Feeding (tube Fed) (0)
CL Item
10= Cold Liquids (10)
CL Item
100= Full Diet (no Restrictions) (100)
CL Item
20= Warm Liquids (20)
CL Item
30= Pureed Foods (in Blender) (30)
CL Item
40= Soft Foods Requiring No Chewing (e.g., Mashed Potatoes, Apple Sauce, Pudding) (40)
CL Item
50= Soft, Chewable Foods (e.g., Macaroni, Canned/soft Fruits, Cooked Vegetables, Fish, Hamburger, Small Pieces Of Meat) (50)
CL Item
60= Dry Bread And Crackers (60)
CL Item
70= Raw Carrots, Celery (70)
CL Item
80= All Meat (80)
CL Item
90= Full Diet (liquid Assist) (90)
Item
Public Eating Rating
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)
Code List
Public Eating Rating
CL Item
0= Always Eats Alone (0)
CL Item
100= No Restriction Of Place, Food Or Companion (eats Out At Any Opportunity) (100)
CL Item
25= Eats Only At Home In Presence Of Selected Persons (25)
CL Item
50= Eats Only In Presence Of Selected Persons In Selected Places (50)
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)
Item
Understandability of Speech Rating
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)
Code List
Understandability of Speech Rating
CL Item
0= Never Understandable; May Use Written Communication (0)
CL Item
100= Always Understandable (100)
CL Item
25= Difficult To Understand (25)
CL Item
50= Usually Understandable; Face-to-face Contact Necessary (50)
CL Item
75= Understandable Most Of The Time; Occasional Repetition Necessary (75)
Item Group
Comments
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
Responsible Person Signature Text
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Form Completion Date
Item
Date Form Originally Completed
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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