ID

11470

Beskrivning

NCT00087178 NSABP Protocol B-36 Missing Data Form for Quality of Life Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C8CBE2C5-1EEF-3461-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C8CBE2C5-1EEF-3461-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2014-12-18 2014-12-18 - Martin Dugas
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-07-05 2015-07-05 -
Uppladdad den

5 juli 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

NCT00087178 NSABP Protocol B-36 Missing Data Form for Quality of Life Questionnaire

Engelsk

Submit this form to the NSABP Biostatistical Center whenever a protocol-scheduled Quality of Life Questionnaire (QOL) or Menstrual History Form (MH-F) is not filled out by the patient and the assessment cannot be obtained by phone or mail.

1 Formulär  
Header
Beskrivning

Header

Patient Initials (Last, First Middle)
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NSABP Patient ID
Beskrivning

Patient ID NSABP

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
Institution Name
Beskrivning

Institution Name

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Affiliate Name
Beskrivning

Affiliate Name

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS CUI-1
C1510825
NCI Thesaurus ObjectClass-2
C25413
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Person Completing Form (First Name)
Beskrivning

Person Completing Form

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Person Completing Form (First Name)
Beskrivning

Person Completing Form

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Person Completing Form (Phone)
Beskrivning

Person Completing Form Phone

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
UMLS CUI-2
C1515258
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25395
Today's Date (Month Day Year)
Beskrivning

Today'sDate

Datatyp

text

Are data amended?
Beskrivning

Data amended

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Missing Data Form for Quality of Life Questionnaire
Beskrivning

Missing Data Form for Quality of Life Questionnaire

Time Point for this Form (mark one)
Beskrivning

AbsentQualityofLifeAssessmentPeriodType

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C20989
UMLS 2011AA ObjectClass-2
C0031809
NCI Thesaurus ObjectClass-3
C48190
UMLS 2011AA ObjectClass-3
C0332197
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Form(s) missing (mark one or both)
Beskrivning

CaseReportFormAbsent

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
Beskrivning

QualityOfLifeNotAssessedReason

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Reason QOL/MH-F was Not Obtained by Phone or Mail (Mark all that apply and add comments below.)
Beskrivning

QualityOfLifeNotAssessedReason

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Other (specify)
Beskrivning

QualityOfLifeNotAssessedSpecifiedReason

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Other (specify)
Beskrivning

QualityOfLifeNotAssessedSpecifiedReason

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Comments
Beskrivning

Comments

Comments
Beskrivning

Research Comments

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire
Beskrivning

Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire

Tillbaka till toppen

Similar models

Submit this form to the NSABP Biostatistical Center whenever a protocol-scheduled Quality of Life Questionnaire (QOL) or Menstrual History Form (MH-F) is not filled out by the patient and the assessment cannot be obtained by phone or mail.

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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)
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)
Affiliate Name
Item
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 (First Name)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Person Completing Form
Item
Person Completing Form (First Name)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Person Completing Form Phone
Item
Person Completing Form (Phone)
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
Today'sDate
Item
Today's Date (Month Day Year)
text
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
Missing Data Form for Quality of Life Questionnaire
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
6 month follow-up (6 month follow-up)
CL Item
Day 1 of Cycle #4 (Day 1 of Cycle #4)
CL Item
12 month follow-up (12 month follow-up)
CL Item
18 month follow-up (18 month follow-up)
CL Item
24 month follow-up (24 month follow-up)
CL Item
30 month follow-up (30 month follow-up)
CL Item
36 month follow-up (36 month follow-up)
CL Item
42 month follow-up (42 month follow-up)
Item
Form(s) missing (mark one or both)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
CL.3
Code List
Form(s) missing (mark one or both)
CL Item
QOL (QOL)
CL Item
MH-F (MH-F)
Item
Reason QOL/MH-F 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)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL.5
Code List
Reason QOL/MH-F 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 to complete questionnaire (Patient refused to complete questionnaire)
CL Item
Questionnaire was mailed to patient but she did not return it (Questionnaire was mailed to patient but she did not return it)
CL Item
Other (specify) (Other (specify))
Item
Reason QOL/MH-F 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)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL.5
Code List
Reason QOL/MH-F 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 to complete questionnaire (Patient refused to complete questionnaire)
CL Item
Questionnaire was mailed to patient but she did not return it (Questionnaire was mailed to patient but she did not return it)
CL Item
Other (specify) (Other (specify))
QualityOfLifeNotAssessedSpecifiedReason
Item
Other (specify)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
QualityOfLifeNotAssessedSpecifiedReason
Item
Other (specify)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Ccrr Module For Nsabp Protocol B-36 Missing Data Form For Quality Of Life Questionnaire
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial