ID

10622

Beschreibung

CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CCBC1-A49F-3714-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CCBC1-A49F-3714-E034-080020C9C0E0

Stichworte

  1. 26.08.12 26.08.12 -
  2. 22.05.15 22.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

3. Juni 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM 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.

CALGB clinical trial administrative data
Beschreibung

CALGB clinical trial administrative data

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (M)
Beschreibung

DateCompleted

Datentyp

date

Amended data?
Beschreibung

Amendeddata?

Datentyp

text

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Responsible CRA
Beschreibung

ResponsibleCRA

Datentyp

text

Assessment Number (ADDITIONAL PHYSICAL PROBLEMS DUE TO CANCER TREATMENT [SIDE EFFECTS])
Beschreibung

AssessmentNumber

Datentyp

float

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

Physical examination
Beschreibung

Physical examination

Alias
UMLS CUI-1
C0031809
Mouth sores
Beschreibung

Mouthsores

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Skin changes (such as redness or peeling) on hands or feet
Beschreibung

Skinchanges(suchasrednessorpeeling)onhandsorfeet

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Swelling in hands or feet
Beschreibung

Swellinginhandsorfeet

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Pain in hands or feet (OVERALL QUALITY OF LIFE)
Beschreibung

Paininhandsorfeet

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
what number would you say best describes your current stat of health over just the past two weeks? (3. Imagine that a friend of yours is expected to live for 15 years with the same quality of live as you have now. Suppose treatment could restore your friend to full health, but would shorten his/her life.)
Beschreibung

whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?

Datentyp

float

At most, how much time would you advise your friend to give up out of 15 years in order to return to full health? (months)
Beschreibung

Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?

Datentyp

float

Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment Form
Beschreibung

Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment Form

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 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.

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
Item
Amended data?
text
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (ADDITIONAL PHYSICAL PROBLEMS DUE TO CANCER TREATMENT [SIDE EFFECTS])
float
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
Physical examination
C0031809 (UMLS CUI-1)
Item
Mouth sores
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Mouth sores
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Skin changes (such as redness or peeling) on hands or feet
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Skin changes (such as redness or peeling) on hands or feet
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Swelling in hands or feet
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Swelling in hands or feet
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
Item
Pain in hands or feet (OVERALL QUALITY OF LIFE)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Pain in hands or feet (OVERALL QUALITY OF LIFE)
CL Item
Not At All (Not at All)
C91213 (NCI Thesaurus)
CL Item
A Little (A Little)
CL Item
Quite A Bit (Quite a Bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very Much)
C91217 (NCI Thesaurus)
whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?
Item
what number would you say best describes your current stat of health over just the past two weeks? (3. Imagine that a friend of yours is expected to live for 15 years with the same quality of live as you have now. Suppose treatment could restore your friend to full health, but would shorten his/her life.)
float
Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?
Item
At most, how much time would you advise your friend to give up out of 15 years in order to return to full health? (months)
float
Item Group
Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment Form

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