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ID
11610
Descrição
CALGB: BACKGROUND INFORMATION FORM NCT00041119 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=A50BF263-C019-2D60-E034-080020C9C0E0
Link
Palavras-chave
Versões (3)
- 26/08/2012 26/08/2012 -
- 08/07/2015 08/07/2015 -
- 08/07/2015 08/07/2015 -
Transferido a
8 de julho de 2015
DOI
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Licença
Creative Commons BY-NC 3.0 Legacy
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CALGB: BACKGROUND INFORMATION FORM NCT00041119
THANK YOU VERY MUCH FOR YOUR VOLUNTARY PARTICIPATION! PLEASE RETURN TO THE PERSON WHO HANDED YOU THIS FORM.
- StudyEvent: CALGB: BACKGROUND INFORMATION FORM
Similar models
THANK YOU VERY MUCH FOR YOUR VOLUNTARY PARTICIPATION! PLEASE RETURN TO THE PERSON WHO HANDED YOU THIS FORM.
- StudyEvent: CALGB: BACKGROUND INFORMATION FORM
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Amendeddata?
Item
Amended data?
boolean
Patient's Name
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
Participating Group
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
Patient Hospital Number
Item
Patient Hospital Number
text
C0421459 (UMLS CUI-1)
Participating Group Protocol No.
Item
Participating Group Protocol No.
text
C0008971 (UMLS CUI-1)
C0237753 (UMLS CUI-2)
C0237753 (UMLS CUI-2)
Main Member Institution/Adjunct
Item
Main Member Institution/Adjunct
text
C0680022 (UMLS CUI-1)
C2607850 (UMLS CUI-2)
C2607850 (UMLS CUI-2)
Participating Group Patient No.
Item
Participating Group Patient No.
text
C1830427 (UMLS CUI-1)
C0441833 (UMLS CUI-2)
C0441833 (UMLS CUI-2)
If you do not wish to answer any of the following questions please mark an X here. (1.)
Item
If you do not wish to answer any of the following questions please mark an X here. (1.)
text
Today'sDate
Item
Today's Date (M)
date
Item
What is the highest grade you finished in school? (3.)
text
C3166592 (UMLS CUI-1)
CL Item
1-8 Grades (1-8 grades)
CL Item
9-11 Grades (9-11 grades)
CL Item
High School Graduate (High School graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS CUI-1)
C0870649 (UMLS CUI-1)
CL Item
Some College (Some college)
C1883065 (UMLS CUI-1)
CL Item
Junior College Degree (Junior college degree)
C0681414 (UMLS CUI-1)
CL Item
College Degree (b.a./b.s.) (College degree (B.A./B.S.))
C1552034 (UMLS CUI-1)
CL Item
Some Post-college Work (Some post-college work)
CL Item
Advanced Degree (Advanced degree)
C0556960 (UMLS CUI-1)
Item
What is your marital status? (mark one with an X)
text
C0024819 (UMLS CUI-1)
CL Item
Single, Never Married (Single, never married)
C0037179 (UMLS CUI-1)
C0027952 (UMLS CUI-2)
C0027952 (UMLS CUI-2)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
C0555047 (UMLS CUI-1)
C0555047 (UMLS CUI-1)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS CUI-1)
C0086972 (UMLS CUI-1)
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
C0086170 (UMLS CUI-1)
C0086170 (UMLS CUI-1)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS CUI-1)
C0206275 (UMLS CUI-1)
Item
With whom do you live? (mark all that apply with an X)
text
C0020052 (UMLS CUI-1)
C0018677 (UMLS CUI-2)
C0018677 (UMLS CUI-2)
CL Item
Spouse/partner (Spouse/Partner)
C0162409 (UMLS CUI-1)
CL Item
Children Aged 18 Years Or Younger (Children aged 18 years or younger)
C0008059 (UMLS CUI-1)
C0026193 (UMLS CUI-2)
C0026193 (UMLS CUI-2)
CL Item
Children Aged 19 Years Or Older (Children aged 19 years or older)
C0008059 (UMLS CUI-1)
CL Item
Parent(s)/parent(s)-in-law (Parent(s)/Parent(s)-In-Law)
CL Item
Other Relative, Specify (Other relative, specify)
C0080103 (UMLS CUI-1)
CL Item
Live Alone (Live alone)
C0439044 (UMLS CUI-1)
CL Item
Other, Specify (Other, specify)
C1707811 (UMLS CUI-1)
C3840932 (UMLS CUI-2)
C3840932 (UMLS CUI-2)
Otherrelative,specify(withwhomyoulive)
Item
Other relative, specify (with whom you live)
text
Other,specify(withwhomyoulive)
Item
Other, specify (with whom you live) (5.)
text
Item
What is your current employment status? (mark all that apply with an X)
text
CL Item
Employed 32 Hours Or More Per Week (Employed 32 hours or more per week)
CL Item
Employed Less Than 32 Hours Per (Employed less than 32 hours per)
CL Item
Full-time Student (Full-time student)
CL Item
Part-time Student (Part-time student)
CL Item
Homemaker (Homemaker)
C0555052 (NCI Metathesaurus)
CL Item
On Medical Leave (On medical leave)
CL Item
Disabled (Disabled)
C63367 (NCI Thesaurus)
C1880351 (UMLS 2011AA)
C1880351 (UMLS 2011AA)
CL Item
Unemployed (Unemployed)
C0425086 (NCI Metathesaurus)
CL Item
Retired (Retired)
CL Item
Other, Specify (Other, specify)
Other,specify(currentemploymentstatus)
Item
Other, specify (current employment status)
text