This paper worksheet may be completed to facilitate entry of information in NSABP Coordination Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. Submit Form QMD online whenever the protocol-scheduled Medical Conditions and Lifestyle Questionnaire Follow-up (MCL-F) form is not filled out by the patient and the assessment cannot be obtained by phone or mail. No missing data form is required for partially completed MCL-F forms

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
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)
Patient ID NSABP
Item
NSABP Patient ID
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)
Item Group
Reason Qol Not Assessed
Item
Time point
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.1
Code List
Time point
CL Item
12 Months Post Randomization (12 months post randomization)
CL Item
24 Months Post Randomization (24 months post randomization)
CL Item
36 Months Post Randomization (36 months post randomization)
CL Item
48 Months Post Randomization (48 months post randomization)
CL Item
60 Months Post Randomization (60 months post randomization)
Item
Reason MCL-F was Not Assessed During Clinic Visit (Mark the main reason and add comments below)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL.2
Code List
Reason MCL-F was Not Assessed During Clinic Visit (Mark the main reason and add comments below)
CL Item
Patient Stated That She Was Too Ill Or Upset To Complete Questionnaire (Patient stated that she was too ill or upset to complete questionnaire)
CL Item
Staff Concerned For Patient's Medical Or Emotional Condition (Staff concerned for patient's medical or emotional condition)
CL Item
Patient Refused To Complete Questionnaire For Reason Other Than Illness Or Upset (Patient refused to complete questionnaire for reason other than illness or upset)
CL Item
Patient Was Unavailable (e.g., Scheduling Or Transportation Difficulties) (Patient was unavailable)
CL Item
Staff Oversight Or Understaffing (Staff oversight or understaffing)
CL Item
Other, Specify (Other)
Item
Reason MCL-F was Not Assessed by Phone or Mail (Mark the main reason 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.3
Code List
Reason MCL-F was Not Assessed by Phone or Mail (Mark the main reason 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 To Complete Questionnaire (Patient refused to complete questionnaire)
CL Item
Questionnaire Was Mailed To Patient, But She Did Not Return It (for Unknown Reasons) (QUESTIONNAIRE WAS MAILED TO PATIENT, BUT SHE DID NOT RETURN IT)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
QualityOfLifePatientNotAssessedSpecify
Item
Other, specify
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass-2)
C0030705 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property-2)
C1518422 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
QualityOfLifePatientNotAssessedSpecify
Item
Other, specify
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass-2)
C0030705 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25594 (NCI Thesaurus Property-2)
C1518422 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Footer
Research Comments
Item
Comments (optional)
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form
Item
Person Completing Form
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
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)
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