ID

10237

Beschreibung

CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD 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=A50CE624-6F5F-37E3-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CE624-6F5F-37E3-E034-080020C9C0E0

Stichworte

  1. 26.08.12 26.08.12 -
  2. 20.05.15 20.05.15 - Martin Dugas
Hochgeladen am

20. Mai 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer DRUG SUPPLY NCT00024102 CALGB 49907

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 Statistical Center, Data Operations. 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.

Header
Beschreibung

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Last date of reporting cycle (M)
Beschreibung

Lastdateofreportingcycle

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Amended data?
Beschreibung

Amended data?

Datentyp

boolean

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

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

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Adjunct

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientNo.

Datentyp

text

Drug Supply
Beschreibung

Drug Supply

Daily capecitabine dose (mg)
Beschreibung

Dailycapecitabinedose

Datentyp

float

Number of 500 mg tablets prescribed to be taken each day
Beschreibung

Numberof500mgtabletsprescribedtobetakeneachday

Datentyp

float

Number of 500 mg tablets issued
Beschreibung

Numberof500mgtabletsissued

Datentyp

float

Date and time the electronic device was placed on the vial (Use a military-24 hour clock)
Beschreibung

Dateandtimetheelectronicdevicewasplacedonthevial

Datentyp

text

Name of the person who filled the vial (Use a military-24 hour clock)
Beschreibung

Nameofthepersonwhofilledthevial

Datentyp

text

Date and Time pill count was done
Beschreibung

DateandTimepillcountwasdone

Datentyp

text

How many 500 mg tablets returned (Exact pill count)
Beschreibung

Howmany500mgtabletsreturned

Datentyp

float

Date and time the electronic device was removed from the vial (Use a military-24 hour clock)
Beschreibung

Dateandtimetheelectronicdevicewasremovedfromthevial

Datentyp

text

Name of the person who performed the return pill count
Beschreibung

Nameofthepersonwhoperformedthereturnpillcount

Datentyp

text

Completed By (Print or Type Name)
Beschreibung

CompletedBy

Datentyp

text

Date Completed (M)
Beschreibung

DateCompleted

Datentyp

date

Ähnliche Modelle

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 Statistical Center, Data Operations. 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
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Lastdateofreportingcycle
Item
Last date of reporting cycle (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Amendeddata?
Item
Amended data?
boolean
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
Item Group
Drug Supply
Dailycapecitabinedose
Item
Daily capecitabine dose (mg)
float
Numberof500mgtabletsprescribedtobetakeneachday
Item
Number of 500 mg tablets prescribed to be taken each day
float
Numberof500mgtabletsissued
Item
Number of 500 mg tablets issued
float
Dateandtimetheelectronicdevicewasplacedonthevial
Item
Date and time the electronic device was placed on the vial (Use a military-24 hour clock)
text
Nameofthepersonwhofilledthevial
Item
Name of the person who filled the vial (Use a military-24 hour clock)
text
DateandTimepillcountwasdone
Item
Date and Time pill count was done
text
Howmany500mgtabletsreturned
Item
How many 500 mg tablets returned (Exact pill count)
float
Dateandtimetheelectronicdevicewasremovedfromthevial
Item
Date and time the electronic device was removed from the vial (Use a military-24 hour clock)
text
Nameofthepersonwhoperformedthereturnpillcount
Item
Name of the person who performed the return pill count
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date

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