ID

10237

Beschrijving

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

Trefwoorden

  1. 26-08-12 26-08-12 -
  2. 20-05-15 20-05-15 - Martin Dugas
Geüploaded op

20 mei 2015

DOI

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Licentie

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
Beschrijving

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBStudyNo

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Last date of reporting cycle (M)
Beschrijving

Lastdateofreportingcycle

Datatype

date

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

Amended data?

Datatype

boolean

Patient's Name
Beschrijving

Patient'sName

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

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

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Adjunct

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientNo.

Datatype

text

Drug Supply
Beschrijving

Drug Supply

Daily capecitabine dose (mg)
Beschrijving

Dailycapecitabinedose

Datatype

float

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

Numberof500mgtabletsprescribedtobetakeneachday

Datatype

float

Number of 500 mg tablets issued
Beschrijving

Numberof500mgtabletsissued

Datatype

float

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

Dateandtimetheelectronicdevicewasplacedonthevial

Datatype

text

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

Nameofthepersonwhofilledthevial

Datatype

text

Date and Time pill count was done
Beschrijving

DateandTimepillcountwasdone

Datatype

text

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

Howmany500mgtabletsreturned

Datatype

float

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

Dateandtimetheelectronicdevicewasremovedfromthevial

Datatype

text

Name of the person who performed the return pill count
Beschrijving

Nameofthepersonwhoperformedthereturnpillcount

Datatype

text

Completed By (Print or Type Name)
Beschrijving

CompletedBy

Datatype

text

Date Completed (M)
Beschrijving

DateCompleted

Datatype

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)
Datatype
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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