ID

10237

Description

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

Lien

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

Mots-clés

  1. 26/08/2012 26/08/2012 -
  2. 20/05/2015 20/05/2015 - Martin Dugas
Téléchargé le

20 mai 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy

Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

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
Description

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Description

CALGBForm

Type de données

text

CALGB Study No
Description

CALGBStudyNo

Type de données

text

CALGB Patient ID
Description

CALGBPatientID

Type de données

text

Last date of reporting cycle (M)
Description

Lastdateofreportingcycle

Type de données

date

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

Amended data?

Type de données

boolean

Patient's Name
Description

Patient'sName

Type de données

text

Participating Group
Description

ParticipatingGroup

Type de données

text

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

PatientHospitalNumber

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Type de données

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Type de données

text

Drug Supply
Description

Drug Supply

Daily capecitabine dose (mg)
Description

Dailycapecitabinedose

Type de données

float

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

Numberof500mgtabletsprescribedtobetakeneachday

Type de données

float

Number of 500 mg tablets issued
Description

Numberof500mgtabletsissued

Type de données

float

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

Dateandtimetheelectronicdevicewasplacedonthevial

Type de données

text

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

Nameofthepersonwhofilledthevial

Type de données

text

Date and Time pill count was done
Description

DateandTimepillcountwasdone

Type de données

text

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

Howmany500mgtabletsreturned

Type de données

float

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

Dateandtimetheelectronicdevicewasremovedfromthevial

Type de données

text

Name of the person who performed the return pill count
Description

Nameofthepersonwhoperformedthereturnpillcount

Type de données

text

Completed By (Print or Type Name)
Description

CompletedBy

Type de données

text

Date Completed (M)
Description

DateCompleted

Type de données

date

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 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
Type
Description | Question | Decode (Coded Value)
Type de données
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

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial