INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Form ID CALGB
Item
CALGB Form
text
C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
Protocol ID CALGB
Item
CALGB Study No
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Date Form Completed
Item
Date Form Completed
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Data amended
Item
Are data amended
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Patient demographics
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Participating Group
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Health Before Cancer Diagnosis
CardiovascularDiseasePresentInd-2
Item
Do you have heart disease
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25292 (NCI Thesaurus ObjectClass)
C0007226 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
HypertensionDiseasePresentInd-2
Item
Do you have high blood pressure
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3117 (NCI Thesaurus ObjectClass)
C0020538 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
DiseaseEmphysemaBronchitisPresentInd-3
Item
Do you have emphysema or bronchitis
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2911 (NCI Thesaurus Property-2)
C0006277 (UMLS 2011AA Property-2)
C3348 (NCI Thesaurus Property-3)
C0034067 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
DiabetesMellitusDiseasePresentInd-2
Item
Do you have diabetes
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C2985 (NCI Thesaurus ObjectClass-2)
C0011849 (UMLS 2011AA ObjectClass-2)
DiseaseStomachPresentInd-3
Item
Do you have ulcers or stomach disease
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12391 (NCI Thesaurus Property-2)
C0038351 (UMLS 2011AA Property-2)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
KidneyDiseasePresentInd-3
Item
Do you have kidney disease
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12415 (NCI Thesaurus ObjectClass)
C0022646 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
DiseaseBloodPresentInd-3
Item
Do you have anemia or other blood disease
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus Property-2)
C0229664 (UMLS 2011AA Property-2)
DiseaseDepressionPresentInd-3
Item
Do you have depression
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2982 (NCI Thesaurus Property-2)
C0011570 (UMLS 2011AA Property-2)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
PatientArthritisPersonalMedicalHistoryInd-3
Item
Do you have arthritis
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C2883 (NCI Thesaurus Property)
C0003864 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
TherapyRequiredInd-2
Item
Do you get treatment for it
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
LimitedWorkHealthAssessmentInd-2
Item
Does it limit your activities
boolean
CL110648 (NCI Metathesaurus ObjectClass)
C0043227 (NCI Metathesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25178 (NCI Thesaurus Property-2)
C0018684 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item Group
Section Ii - Social Support
Item
Someone you can count on to listen when you need to talk
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C71323 (NCI Thesaurus Property-3)
C2584313 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.13
Code List
Someone you can count on to listen when you need to talk
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Some whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C60731 (NCI Thesaurus Property-3)
C1828381 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.17
Code List
Some whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Sometimes (Sometimes)
Item
Some whose advice you really want
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C60731 (NCI Thesaurus Property-3)
C1828381 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.17
Code List
Some whose advice you really want
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Sometimes (Sometimes)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C43367 (NCI Thesaurus Property-3)
C1704726 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.18
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to share your most private worries and fears with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C43367 (NCI Thesaurus Property-3)
C1704726 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.18
Code List
Someone to share your most private worries and fears with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.30
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.30
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone who understands your problems
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C28020 (NCI Thesaurus Property-3)
C0033213 (UMLS 2011AA Property-2)
C72889 (NCI Thesaurus Property-4)
C2346843 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.20
Code List
Someone who understands your problems
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Ii - Social Support
Item
Someone to do something enjoyable with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C62185 (NCI Thesaurus Property-3)
C0242428 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.23
Code List
Someone to do something enjoyable with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to do something enjoyable with
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C62185 (NCI Thesaurus Property-3)
C0242428 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.23
Code List
Someone to do something enjoyable with
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to do things with, to help you get your mind off things
text
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property-2)
C62188 (NCI Thesaurus Property-3)
C0035028 (UMLS 2011AA Property-2)
CL.24
Code List
Someone to do things with, to help you get your mind off things
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to do things with, to help you get your mind off things
text
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property-2)
C62188 (NCI Thesaurus Property-3)
C0035028 (UMLS 2011AA Property-2)
CL.24
Code List
Someone to do things with, to help you get your mind off things
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Ii - Social Support
Item
Someone to help you if you were confined to bed
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C45985 (NCI Thesaurus Property-3)
C0004910 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.25
Code List
Someone to help you if you were confined to bed
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to take you to the doctor if you needed it
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C61560 (NCI Thesaurus Property-3)
C16988 (NCI Thesaurus Property-4)
C0031834 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.26
Code List
Someone to take you to the doctor if you needed it
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to prepare meals if you were unable to do it yourself
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C62695 (NCI Thesaurus Property-3)
C0016452 (UMLS 2011AA Property-2)
C25625 (NCI Thesaurus Property-4)
C1521827 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.27
Code List
Someone to prepare meals if you were unable to do it yourself
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to help with daily chores if you were sick
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C37902 (NCI Thesaurus Property-2)
C1521721 (UMLS 2011AA Property)
C53291 (NCI Thesaurus Property-3)
C1708387 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.28
Code List
Someone to help with daily chores if you were sick
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.30
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to turn to for suggestions about how to deal with a personal problem
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C48191 (NCI Thesaurus Property-3)
C1533716 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.30
Code List
Someone to turn to for suggestions about how to deal with a personal problem
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Ii - Social Support
Item
Someone to love and make you feel wanted
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C73509 (NCI Thesaurus Property-3)
C0024028 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.32
Code List
Someone to love and make you feel wanted
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone to love and make you feel wanted
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C73509 (NCI Thesaurus Property-3)
C0024028 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.32
Code List
Someone to love and make you feel wanted
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Someone who hugs you
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C49147 (NCI Thesaurus Property-3)
C0392367 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.33
Code List
Someone who hugs you
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item Group
Section Iii - Demographics
Item
Race
text
C25372 (NCI Thesaurus ValueDomain)
C0034510 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C17049 (NCI Thesaurus Property)
CL.34
Code List
Race
CL Item
A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)
C41259 (NCI Thesaurus)
C1515945 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
C41260 (NCI Thesaurus)
C0078988 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
C16352 (NCI Thesaurus)
C0085756 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)
C41219 (NCI Thesaurus)
C1513907 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not Reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
C41261 (NCI Thesaurus)
C0007457 (UMLS 2011AA)
PatientRaceSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17049 (NCI Thesaurus Property)
C0034510 (UMLS 2011AA Property)
Item
Ethnicity
text
C25372 (NCI Thesaurus ValueDomain)
C0015031 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C16564 (NCI Thesaurus Property)
CL.35
Code List
Ethnicity
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)
C17459 (NCI Thesaurus)
C0086409 (UMLS 2011AA)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
C41222 (NCI Thesaurus)
C1518424 (UMLS 2011AA)
CL Item
Not Provided Or Available (Not reported)
C43234 (NCI Thesaurus)
C1706613 (UMLS 2011AA)
CL Item
Could Not Be Determined Or Unsure (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
What is the highest grade you finished in school?
text
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25525 (NCI Thesaurus ObjectClass)
C1522410 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0013622 (NCI Metathesaurus ObjectClass)
CL.36
Code List
What is the highest grade you finished in school?
CL Item
1-8 Grades (1-8 grades)
CL Item
9-11 Grades (9-11 grades)
CL Item
Advanced Degree (Advanced degree)
CL Item
College Degree (b.a./b.s.) (College degree (B.A./B.S.))
CL Item
High School Graduate (High School graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS 2011AA)
CL Item
Junior College Degree (Junior college degree)
CL Item
Some College (Some college)
CL Item
Some Post-college Work (Some post-college work)
Item
Marital status
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25188 (NCI Thesaurus ObjectClass)
C0024819 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.37
Code List
Marital status
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
CL Item
Domestic Partnership (Domestic Partnership)
C53262 (NCI Thesaurus)
C1549111 (UMLS 2011AA)
CL Item
I Prefer Not To Answer (I prefer not to answer)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Never Married (Never married)
C51774 (NCI Thesaurus)
C0027952 (UMLS 2011AA)
CL Item
Separated (Separated)
CL Item
Unknown/not Reported (Unknown/Not Reported)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
Item
Is the place where you live
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16495 (NCI Thesaurus Property)
C0011292 (UMLS 2011AA Property)
C25273 (NCI Thesaurus Property-2)
C0237096 (UMLS 2011AA Property-2)
C52643 (NCI Thesaurus Property-3)
C0029981 (UMLS 2011AA Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.38
Code List
Is the place where you live
CL Item
Occupied Without Payment Or Cash Rent (Occupied without payment or cash rent)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Owned Or Being Bought By You Or By Someone Who Lives With You (Owned or being bought by you or by someone who lives with you)
CL Item
Rented By You Or By Someone Who Lives With You (Rented by you or by someone who lives with you)
PersonResidenceOwnershipDemographicsSpecify
Item
Other, specify
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C16495 (NCI Thesaurus Property)
C0011292 (UMLS 2011AA Property)
C25273 (NCI Thesaurus Property-2)
C0237096 (UMLS 2011AA Property-2)
C52643 (NCI Thesaurus Property-3)
C0029981 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Method of Payment (The type of health insurance do you currently have)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS 2011AA Property)
CL.39
Code List
Method of Payment (The type of health insurance do you currently have)
CL Item
Medicaid (Medicaid)
C0025071 (NCI Metathesaurus)
CL Item
Medicaid And Medicare (Medicaid and Medicare)
CL Item
Medicare (Medicare)
C16665 (NCI Thesaurus)
C0018717 (UMLS 2011AA)
CL Item
Medicare And Private Insurance (Medicare and Private Insurance)
CL Item
Military Or Veterans Sponsored Nos (Military or Veterans Sponsored, Not Otherwise Specified (NOS))
CL Item
Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
CL Item
No Means Of Payment (no Insurance) (No means of payment (no insurance))
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Private Insurance (Private Insurance)
CL Item
Self Pay (no Insurance) (Self Pay (No Insurance))
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Veterans Sponsored (Veterans Sponsored)
PatientPaymentSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25371 (NCI Thesaurus Property)
C0680264 (UMLS 2011AA Property)
Item
When you go to the drug store to get your medications, do you have trouble coming up with the money to pay for them
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C459 (NCI Thesaurus Property-2)
C0013227 (UMLS 2011AA Property)
C25371 (NCI Thesaurus Property-3)
C0680264 (UMLS 2011AA Property-2)
C62189 (NCI Thesaurus Property-4)
C1299586 (UMLS 2011AA Property-3)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
CL.40
Code List
When you go to the drug store to get your medications, do you have trouble coming up with the money to pay for them
CL Item
A Little Of The Time (A little of the time)
CL Item
All Of The Time (All of the time)
CL Item
Most Of The Time (Most of the time)
CL Item
None Of The Time (None of the time)
CL Item
Some Of The Time (Some of the time)
Item
Household Income (your best estimate of your family income last year, including income from all sources, before taxes)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25688 (NCI Thesaurus Property)
C0449438 (UMLS 2011AA Property)
C70811 (NCI Thesaurus ObjectClass)
C0557163 (UMLS 2011AA ObjectClass)
CL.41
Code List
Household Income (your best estimate of your family income last year, including income from all sources, before taxes)
CL Item
$15,001 - $20,000 ($15,001 - $20,000)
CL Item
$20,001 - $30,000 ($20,001 - $30,000)
CL Item
$30,001 - $45,000 ($30,001 - $45,000)
CL Item
$45,001 - $60,000 ($45,001 - $60,000)
CL Item
$60,001 - $75,000 ($60,001 - $75,000)
CL Item
Less Than $15,000 (Less than $15,000)
CL Item
More Than $75,000 (More than $75,000)
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