ID

10622

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-05-22 2015-05-22 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

3 juni 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy

Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

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
Beskrivning

CALGB clinical trial administrative data

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBStudyNo

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Date Completed (M)
Beskrivning

DateCompleted

Datatyp

date

Amended data?
Beskrivning

Amendeddata?

Datatyp

text

Patient's Name
Beskrivning

Patient'sName

Datatyp

text

Responsible CRA
Beskrivning

ResponsibleCRA

Datatyp

text

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

AssessmentNumber

Datatyp

float

Participating Group
Beskrivning

ParticipatingGroup

Datatyp

text

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

PatientHospitalNumber

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Main Member Institution/Adjunct
Beskrivning

MainMemberInstitution/Adjunct

Datatyp

text

Participating Group Patient No.
Beskrivning

ParticipatingGroupPatientNo.

Datatyp

text

Physical examination
Beskrivning

Physical examination

Alias
UMLS CUI-1
C0031809
Mouth sores
Beskrivning

Mouthsores

Datatyp

text

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

Skinchanges(suchasrednessorpeeling)onhandsorfeet

Datatyp

text

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

Swellinginhandsorfeet

Datatyp

text

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

Paininhandsorfeet

Datatyp

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.)
Beskrivning

whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?

Datatyp

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)
Beskrivning

Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?

Datatyp

float

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

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

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.

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

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