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1 forms
  1. StudyEvent: NSABP Protocol R-04 Missing Data Form for Quality of Life Questionnaire
    1. Mark Circle Like This
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Nsabp Protocol R-04 Missing Data Form For Quality Of Life Questionnaire
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patients Last Name
text
Patient ID NSABP
Item
Patient Study ID 34
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Affiliate Name
Item
Institution Name / Affiliate Name
text
C21541 (NCI Thesaurus ObjectClass)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Person Completing Form
Item
Person Completing Form
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Person Completing Form Last Name
Item
Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form First Name
Item
First Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Data amended
Item
Are Data Amended?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item
Time Point for this Form (mark one)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus ObjectClass-2)
C0031809 (UMLS 2011AA ObjectClass-2)
C48190 (NCI Thesaurus ObjectClass-3)
C0332197 (UMLS 2011AA ObjectClass-3)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Time Point for this Form (mark one)
CL Item
Post Chemotherapy/radiation (Post chemotherapy/radiation)
CL Item
One Year After Surgery (One year after surgery)
Agent
Item
Other (specify)
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
Agent
Item
Other (specify)
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
Item
Reason QOL was Not Assessed During Clinic Visit (Mark the main reason and add comments below.)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus ObjectClass-2)
C0031809 (UMLS 2011AA ObjectClass-2)
C48190 (NCI Thesaurus ObjectClass-3)
C0332197 (UMLS 2011AA ObjectClass-3)
C25716 (NCI Thesaurus Property)
C0545082 (UMLS 2011AA Property)
C0442592 (NCI Metathesaurus Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.4
Code List
Reason QOL was Not Assessed During Clinic Visit (Mark the main reason and add comments below.)
CL Item
Staff Oversight Or Understaffing (Staff oversight or understaffing)
CL Item
Patient Was Unavailable (e.g., Scheduling Or Transportation Difficulties) (Patient was unavailable)
CL Item
Patient Refused To Complete Questionnaire (Patient refused to complete qustionnaire)
CL Item
Clinical Staff Concerned For Patient's Medical Or Emotional Condition (Clinical staff concerned for patinet's medical or emotional condition)
CL Item
Patient Felt Too Ill Or Emotionally Upset (Patient felt too ill or emotionally upset)
Item
Reason QOL was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C48190 (NCI Thesaurus Property-2)
C0332197 (UMLS 2011AA Property-2)
CL.5
Code List
Reason QOL was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
CL Item
Staff Oversight Or Understaffing (Staff oversight or understaffing)
CL Item
Staff Was Unable To Contact Patient By Phone (Staff was unable to contact patient by phone)
CL Item
Patient Refused (Patient refused)
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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