ID
10082
Description
CALGB: SOCIAL SUPPORT FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF99D-12AE-2D64-E034-080020C9C0E0
Link
Keywords
Versions (2)
- 12/18/14 12/18/14 - Martin Dugas
- 3/23/15 3/23/15 - Martin Dugas
Uploaded on
March 23, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102
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.
Description
Social support
Alias
- UMLS CUI-1
- C0037438
Description
Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Data type
integer
Alias
- UMLS CUI-1
- C0079382
- UMLS CUI-2
- C0449788
Description
Someonetohelpifyouwereconfinedtobed
Data type
text
Description
Someoneyoucancountontolistentoyouwhenyouneedtotalk
Data type
text
Description
Someonetogiveyougoodadviceaboutacrisis
Data type
text
Description
Someonetotakeyoutothedoctorifyouneededit
Data type
text
Description
Someonewhoshowsyouloveandaffection
Data type
text
Description
Someonetohaveagoodtimewith
Data type
text
Description
Someonetogiveyouinformationtohelpyouunderstandasituation
Data type
text
Description
Someonetoconfideinortalktoaboutyourselforyourproblems
Data type
text
Description
Someone who hugs you (11.)
Data type
text
Description
Someonetogettogetherwithforrelaxation
Data type
text
Description
Someone to prepare your meals if you were unable to do it yourself (13.)
Data type
text
Description
Someone whose advice you really want (14.)
Data type
text
Description
Someone to do things with to help you get your mind off things (15.)
Data type
text
Description
Someone to help you with daily chores if you were sick (16.)
Data type
text
Description
Someone to share your most private worries and fears with (17.)
Data type
text
Description
Someone to turn to for suggestions about how to deal with a personal problem (18.)
Data type
text
Description
Someone to do something enjoyable with (19.)
Data type
text
Description
Someone who understands your problems (20.)
Data type
text
Description
Someone to love and make you feel wanted
Data type
text
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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0449788 (UMLS CUI-2)