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.

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)
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)
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)
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)
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)
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

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