Information: Due to increasing bot activity we were unfortunately forced to place the search behind a login. Links to models can still be shared with others and viewed without a login. Thank you for your understanding.
Information: This is an outdated version of the data model. You can find a Versions overview via Versions on the left. You can find the newest Version by clicking here.
Information:
Error:
ID
736
Description
CALGB: QOL ASSESSMENT SUMARY FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D1BCF-4910-2EA3-E034-080020C9C0E0
Link
Keywords
Versions (3)
- 8/26/12 8/26/12 -
- 7/8/15 7/8/15 -
- 7/8/15 7/8/15 -
Uploaded on
August 26, 2012
DOI
To request one please log in.
License
Creative Commons BY-NC 3.0 Legacy
Model comments :
You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.
Itemgroup comments for :
Item comments for :
In order to download data models you must be logged in. Please log in or register for free.
Breast Cancer NCT00024102 Quality of Life - CALGB: QOL ASSESSMENT SUMARY FORM - 2037828v3.0
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. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Similar models
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. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
InterviewerorCRA
Item
Interviewer or CRA
text
AssessmentNumber
Item
Assessment Number
double
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
CL Item
Telephone Interview (Telephone interview)
CL Item
Mailed Questionnaire (Mailed questionnaire)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
double
Item
Language in which assessment was conducted (mark one with an X)
text
CL Item
English (English)
C43853 (NCI Thesaurus)
C1556083 (UMLS 2011AA)
C1556083 (UMLS 2011AA)
CL Item
Spanish (Spanish)
CL Item
French (French)
CL Item
Other, Specify (Other, specify)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify (language in which assessment was conducted)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Quality of life assessment (mark one with an X)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
CL Item
Completed (Completed)
CL Item
Partially Completed (Partially completed)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
double
Item
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
text
Code List
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
CL Item
Patient Too Medically Ill (Patient too medically ill)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Died (Patient died)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Patient Refuses (Patient refuses)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify (reason assessment was partially completed or not done)
text