CALGB: STRESSFUL LIFE EVENTS FORM NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder:

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3 giugno 2015

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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
Amended data?
Patient demographics
Stressful events
Death of spouse (Occurred in Past Year?)
Death of close family member (3.)
Major personal injury or illness (4.)
Being fired from work (5.)
Divorce (6.)
Major change in financial state (7.)
Retirement (8.)
Marital separation from mate (9.)
Marriage (10.)
Death of close friend (11.)
Major illness of family member (12.)
Major change in leisure or other enjoyable activities (13.)
Change in responsibilities at work (14.)
Moved (15.)
Changed to a different line of work (16.)
Spouse stopped working outside the home
Ccrr Module For Calgb: Stressful Life Events Form

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