CALGB: STRESSFUL LIFE EVENTS 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.

1 Formulär

StudyEvent: CALGB: STRESSFUL LIFE EVENTS FORM
1. 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

CALGB clinical trial administrative data

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

Amendeddata?

Item

Amended data?

text

CL.1

Code List

Amended data?

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

Patient demographics

Item Group

Patient demographics

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

ResponsibleCRA

Item

Responsible CRA

text

AssessmentNumber

Item

Assessment Number (Event)

float

Stressful events

Item Group

Stressful events

Deathofspouse

Item

Death of spouse (Occurred in Past Year?)

boolean