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

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF99D-12AE-2D64-E034-080020C9C0E0

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 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

English

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.

1 forms  
Header
Description

Header

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (8.)
Description

DateCompleted

Data type

date

Amended data?
Description

Amendeddata?

Data type

text

Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Responsible CRA
Description

ResponsibleCRA

Data type

text

Assessment Number (1.)
Description

AssessmentNumber

Data type

float

Social support
Description

Social support

Alias
UMLS CUI-1
C0037438
About how many close friends and close relatives do you have now (people you feel at ease with and can talk to about what is on your mind)? ([Number of close friends/relatives])
Description

Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?

Data type

integer

Alias
UMLS CUI-1
C0079382
UMLS CUI-2
C0449788
Someone to help if you were confined to bed (3.)
Description

Someonetohelpifyouwereconfinedtobed

Data type

text

Someone you can count on to listen to you when you need to talk (4.)
Description

Someoneyoucancountontolistentoyouwhenyouneedtotalk

Data type

text

Someone to give you good advice about a crisis (5.)
Description

Someonetogiveyougoodadviceaboutacrisis

Data type

text

Someone to take you to the doctor if you needed it (6.)
Description

Someonetotakeyoutothedoctorifyouneededit

Data type

text

Someone who shows you love and affection (7.)
Description

Someonewhoshowsyouloveandaffection

Data type

text

Someone to have a good time with
Description

Someonetohaveagoodtimewith

Data type

text

Someone to give you information to help you understand a situation (9.)
Description

Someonetogiveyouinformationtohelpyouunderstandasituation

Data type

text

Someone to confide in or talk to about yourself or your problems (10.)
Description

Someonetoconfideinortalktoaboutyourselforyourproblems

Data type

text

Someone who hugs you (11.)
Description

Someone who hugs you (11.)

Data type

text

Someone to get together with for relaxation (12.)
Description

Someonetogettogetherwithforrelaxation

Data type

text

Someone to prepare your meals if you were unable to do it yourself (13.)
Description

Someone to prepare your meals if you were unable to do it yourself (13.)

Data type

text

Someone whose advice you really want (14.)
Description

Someone whose advice you really want (14.)

Data type

text

Someone to do things with to help you get your mind off things (15.)
Description

Someone to do things with to help you get your mind off things (15.)

Data type

text

Someone to help you with daily chores if you were sick (16.)
Description

Someone to help you with daily chores if you were sick (16.)

Data type

text

Someone to share your most private worries and fears with (17.)
Description

Someone to share your most private worries and fears with (17.)

Data type

text

Someone to turn to for suggestions about how to deal with a personal problem (18.)
Description

Someone to turn to for suggestions about how to deal with a personal problem (18.)

Data type

text

Someone to do something enjoyable with (19.)
Description

Someone to do something enjoyable with (19.)

Data type

text

Someone who understands your problems (20.)
Description

Someone who understands your problems (20.)

Data type

text

Someone to love and make you feel wanted
Description

Someone to love and make you feel wanted

Data type

text

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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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (8.)
date
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
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)
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
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
float
Item Group
Social support
C0037438 (UMLS CUI-1)
number of close friends
Item
About how many close friends and close relatives do you have now (people you feel at ease with and can talk to about what is on your mind)? ([Number of close friends/relatives])
integer
C0079382 (UMLS CUI-1)
C0449788 (UMLS CUI-2)
Item
Someone to help if you were confined to bed (3.)
text
CL.2
Code List
Someone to help if you were confined to bed (3.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone you can count on to listen to you when you need to talk (4.)
text
CL.3
Code List
Someone you can count on to listen to you when you need to talk (4.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to give you good advice about a crisis (5.)
text
CL.4
Code List
Someone to give you good advice about a crisis (5.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to take you to the doctor if you needed it (6.)
text
CL.5
Code List
Someone to take you to the doctor if you needed it (6.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who shows you love and affection (7.)
text
CL.6
Code List
Someone who shows you love and affection (7.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to have a good time with
text
CL.7
Code List
Someone to have a good time with
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to give you information to help you understand a situation (9.)
text
CL.8
Code List
Someone to give you information to help you understand a situation (9.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to confide in or talk to about yourself or your problems (10.)
text
CL.9
Code List
Someone to confide in or talk to about yourself or your problems (10.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who hugs you (11.)
text
CL.10
Code List
Someone who hugs you (11.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to get together with for relaxation (12.)
text
CL.11
Code List
Someone to get together with for relaxation (12.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to prepare your meals if you were unable to do it yourself (13.)
text
CL.12
Code List
Someone to prepare your meals if you were unable to do it yourself (13.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone whose advice you really want (14.)
text
CL.13
Code List
Someone whose advice you really want (14.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to do things with to help you get your mind off things (15.)
text
CL.14
Code List
Someone to do things with to help you get your mind off things (15.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to help you with daily chores if you were sick (16.)
text
CL.15
Code List
Someone to help you with daily chores if you were sick (16.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to share your most private worries and fears with (17.)
text
CL.16
Code List
Someone to share your most private worries and fears with (17.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to turn to for suggestions about how to deal with a personal problem (18.)
text
CL.17
Code List
Someone to turn to for suggestions about how to deal with a personal problem (18.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to do something enjoyable with (19.)
text
CL.18
Code List
Someone to do something enjoyable with (19.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who understands your problems (20.)
text
CL.19
Code List
Someone who understands your problems (20.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to love and make you feel wanted
text
CL.20
Code List
Someone to love and make you feel wanted
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
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