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  1. StudyEvent: PRL1013 - Week 4 Recall Evaluation Form
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PractitionersEngagedinAppliedResearchandLearningNetworkClinicalStudySiteIdentifierNumber
Item
Site Code
text
C15206 (NCI Thesaurus ObjectClass)
C0008972 (UMLS 2011AA ObjectClass)
C37901 (NCI Thesaurus ObjectClass-2)
C0205145 (UMLS 2011AA ObjectClass-2)
C52664 (NCI Thesaurus ObjectClass-3)
C1709628 (UMLS 2011AA ObjectClass-3)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientDentistVisitDate
Item
Date of visit
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C52654 (NCI Thesaurus Property)
C0011441 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Patient Study ID
Item
Subject ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Patient Initials
Item
Subject Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item
Treatment arm
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C1522541 (UMLS CUI-1)
C32141 (NCI Thesaurus Property)
C25426 (NCI Thesaurus Property-2)
C25284 (NCI Thesaurus ValueDomain)
Code List
Treatment arm
CL Item
Restoration With Rmgi (RR)
CL Item
Restoration With Dba (RD)
Item Group
Dental status
Assessment Date
Item
Date of evaluation
date
C25164 (NCI Thesaurus ValueDomain)
C2985720 (UMLS CUI-1)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C38000 (NCI Thesaurus Property)
Item
Tooth quadrant
text
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12421 (NCI Thesaurus Property-2)
C0226896 (UMLS 2011AA Property-2)
C61106 (NCI Thesaurus Property-3)
C1631280 (UMLS 2011AA Property-3)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
Code List
Tooth quadrant
CL Item
Lower Left Quadrant (Lower Left)
CL Item
Lower Right Quadrant (Lower Right)
CL Item
Upper Left Quadrant (Upper Left)
CL Item
Upper Right Quadrant (Upper Right)
DentalInstrumentationFollow-upAirSpeedDescriptionValue
Item
Air velocity
float
C41136 (NCI Thesaurus ObjectClass)
C0226984 (UMLS 2011AA ObjectClass)
C16742 (NCI Thesaurus ObjectClass-2)
C0348000 (UMLS 2011AA ObjectClass-2)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
C73434 (NCI Thesaurus Property-3)
C0001861 (UMLS 2011AA Property-3)
C41146 (NCI Thesaurus Property-4)
C0678536 (UMLS 2011AA Property-4)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
Item
Air stimulation pain level
text
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25201 (NCI Thesaurus ObjectClass-2)
C1522640 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C61406 (NCI Thesaurus Property-2)
C1948023 (UMLS 2011AA Property)
C73434 (NCI Thesaurus Property-3)
C0001861 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Air stimulation pain level
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
ToothRemainingColdSensitivityAssessmentInd-2
Item
Does the pain linger >4 seconds (after removal of air blast)
boolean
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25201 (NCI Thesaurus Property-2)
C1522640 (UMLS 2011AA Property)
C25649 (NCI Thesaurus Property-3)
C1527428 (UMLS 2011AA Property-2)
C62180 (NCI Thesaurus Property-4)
C0009264 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Cold stimulation pain level
text
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25201 (NCI Thesaurus ObjectClass-2)
C1522640 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C62180 (NCI Thesaurus Property-2)
C0009264 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
Code List
Cold stimulation pain level
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
ToothColdSensitivityAssessmentDuration
Item
Time to cold sensation (length of time from pellet application until subjet raises hand)
float
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25201 (NCI Thesaurus Property-2)
C1522640 (UMLS 2011AA Property)
C62180 (NCI Thesaurus Property-3)
C0009264 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
ToothRemainingHotSensitivityAssessmentInd-2
Item
Does the pain linger > 4 seconds
boolean
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25201 (NCI Thesaurus Property-2)
C1522640 (UMLS 2011AA Property)
C25649 (NCI Thesaurus Property-3)
C1527428 (UMLS 2011AA Property-2)
C62181 (NCI Thesaurus Property-4)
C2350229 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
ToothSensitivityMasticationAssessmentInd-2
Item
During chewing of food
boolean
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25201 (NCI Thesaurus ObjectClass-2)
C1522640 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C62062 (NCI Thesaurus Property-2)
C0024888 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
ToothSensitivityPressureAssessmentInd-2
Item
During clenching
boolean
C12506 (NCI Thesaurus ObjectClass)
C0040426 (UMLS 2011AA ObjectClass)
C25201 (NCI Thesaurus ObjectClass-2)
C1522640 (UMLS 2011AA ObjectClass-2)
C25367 (NCI Thesaurus Property)
C25195 (NCI Thesaurus Property-2)
C0033095 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
DentalOcclusionEvaluationInd-2
Item
Did you check the occlusion on the treated tooth (If "Yes" to either of the above)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C62301 (NCI Thesaurus ObjectClass)
C0011382 (UMLS 2011AA ObjectClass)
DentalOcclusionAdjustmentInd-2
Item
Did you adjust the occlusion (If "Yes")
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C62301 (NCI Thesaurus ObjectClass)
C0011382 (UMLS 2011AA ObjectClass)
C49157 (NCI Thesaurus Property)
C0456081 (UMLS 2011AA Property)
Item Group
Rescue Treatment
RetreatmentAdministeredInd-2
Item
Did the patient receive rescue treatment (since the last visit)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
Item
Which rescue treatment was provided
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
Code List
Which rescue treatment was provided
CL Item
Dental Bonding Agent Dental Liner (Liner+DBA)
C42795 (NCI Thesaurus)
C1707677 (UMLS 2011AA)
C62092 (NCI Thesaurus-3)
C1880280 (UMLS 2011AA-4)
CL Item
Dental Bonding Agent (DBA alone)
C62092 (NCI Thesaurus)
C1880280 (UMLS 2011AA)
CL Item
Not Applicable (N/A)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
RetreatmentAdministeredDate
Item
Date rescue treatment performed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
RetreatmentToothPulpitisAssessmentInd-2
Item
Was the tooth evaluated for pulpitis
boolean
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C12506 (NCI Thesaurus Property-2)
C0040426 (UMLS 2011AA Property)
C52595 (NCI Thesaurus Property-3)
C0034103 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
RetreatmentToothPulpitisPresentInd-2
Item
Was there evidence of pulpitis (If "Yes")
boolean
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12506 (NCI Thesaurus Property-2)
C0040426 (UMLS 2011AA Property-2)
C52595 (NCI Thesaurus Property-3)
C0034103 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
RetreatmentEndodonticTreatmentPerformedInd-2
Item
Was endodontic therapy performed (If "Yes")
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C52575 (NCI Thesaurus Property-2)
C0700632 (UMLS 2011AA Property-2)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
RetreatmentEndodonticTreatmentPerformedDate
Item
Date of endodontic treatment (If "Yes")
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C52575 (NCI Thesaurus Property-2)
C0700632 (UMLS 2011AA Property-2)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
Item Group
Economic Impact
Item
How much time did it take the patient to travel to the dental office today
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C53462 (NCI Thesaurus ObjectClass-2)
C0040802 (UMLS 2011AA ObjectClass-2)
C41136 (NCI Thesaurus Property)
C0226984 (UMLS 2011AA Property)
C25167 (NCI Thesaurus Property-2)
C0012751 (UMLS 2011AA Property-2)
C16988 (NCI Thesaurus Property-3)
C0031834 (UMLS 2011AA Property-3)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Code List
How much time did it take the patient to travel to the dental office today
CL Item
0-15 Minutes (0-15 minutes)
CL Item
16-30 Minutes (16-30 minutes)
CL Item
31-60 Minutes (31-60 minutes)
CL Item
61-90 Minutes (61-90 minutes)
CL Item
91-120 Minutes (91-120 minutes)
CL Item
More Than 120 Minutes (More than 120 minutes)
Item
How much did it cost the patient to travel to the dental office today (including parking)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C53462 (NCI Thesaurus ObjectClass-2)
C0040802 (UMLS 2011AA ObjectClass-2)
C41136 (NCI Thesaurus Property)
C0226984 (UMLS 2011AA Property)
C16988 (NCI Thesaurus Property-2)
C0031834 (UMLS 2011AA Property-2)
C69088 (NCI Thesaurus Property-3)
C0220812 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C69088 (NCI Thesaurus ValueDomain-2)
C0220812 (UMLS 2011AA ValueDomain-2)
Code List
How much did it cost the patient to travel to the dental office today (including parking)
CL Item
$0-10 ($0-10)
CL Item
$11-20 ($11-20)
CL Item
$21-30 ($21-30)
CL Item
More Than $30 (More than $30)
PatientEmploymentAbsentInd-2
Item
Did the patient have to take time away from work to come to the dental office to treat the hypersensitivity
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
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)
Item
How much time did he/she take off (If "Yes")
text
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)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)
Code List
How much time did he/she take off (If "Yes")
CL Item
0-30 Minutes (0-30 minutes)
CL Item
1-2 Hours (1-2 hours)
CL Item
2-3 Hours (2-3 hours)
CL Item
3-4 Hours (3-4 hours)
CL Item
31-60 Minutes (31-60 minutes)
CL Item
More Than 4 Hours (More than 4 hours)
Item
What is the total estimated cost for the rescue treatment if patient was not participating in the study
text
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C54055 (NCI Thesaurus ObjectClass)
C0376495 (UMLS 2011AA ObjectClass)
C69088 (NCI Thesaurus ValueDomain-2)
C0220812 (UMLS 2011AA ValueDomain-2)
Code List
What is the total estimated cost for the rescue treatment if patient was not participating in the study
CL Item
$0-50 ($0-50)
CL Item
$101-150 ($101-150)
CL Item
$151-200 ($151-200)
CL Item
$201-250 ($201-250)
CL Item
$51-100 ($51-100)
CL Item
More Than $250 (More than $250)
Item Group
Footer Module
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

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