ID
11620
Beschreibung
CALGB: QOL ASSESSMENT SUMARY FORM 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=A50D1BCF-4910-2EA3-E034-080020C9C0E0
Link
Stichworte
Versionen (3)
- 26.08.12 26.08.12 -
- 08.07.15 08.07.15 -
- 08.07.15 08.07.15 -
Hochgeladen am
8. Juli 2015
DOI
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Lizenz
Creative Commons BY-NC 3.0 Legacy
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CALGB: QOL ASSESSMENT SUMARY FORM
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.
Beschreibung
Patient data
Alias
- UMLS CUI-1
- C2707520
Beschreibung
Patient's Name
Datentyp
text
Alias
- UMLS CUI-1
- C1299487
Beschreibung
Participating Group
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1257890
- UMLS CUI-2
- C0600091
Beschreibung
Patient Hospital Number
Datentyp
float
Alias
- UMLS CUI-1
- C0421459
Beschreibung
Participating Group Protocol No.
Datentyp
float
Alias
- UMLS CUI-1
- C0332037
Beschreibung
Main Member Institution/Adjunct
Datentyp
float
Alias
- UMLS CUI-1
- C2607850
- UMLS CUI-2
- C0680022
Beschreibung
Participating Group Patient No.
Datentyp
float
Alias
- UMLS CUI-1
- C1830427
- UMLS CUI-2
- C2981590
Beschreibung
Physical assessment
Alias
- UMLS CUI-1
- C0031809
Beschreibung
Method of assessment (mark one with an X)
Datentyp
text
Alias
- UMLS CUI-1
- C2598110
Beschreibung
date questionnaire was sent to patient (M)
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
- UMLS CUI-2
- C2082575
- UMLS CUI-3
- C1519246
Beschreibung
Number of attempts made to contact patient by telephone and/or mail
Datentyp
integer
Alias
- UMLS CUI-1
- C0449788
- UMLS CUI-2
- C0420309
Beschreibung
Language in which assessment was conducted (mark one with an X)
Datentyp
text
Alias
- UMLS CUI-1
- C0424919
- UMLS CUI-2
- C0031809
Beschreibung
Other, specify (language in which assessment was conducted)
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C3845569
- UMLS CUI-2
- C0023008
Beschreibung
Quality of life assessment (mark one with an X)
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- NCI Thesaurus Property
- C25217
- UMLS CUI-1
- C0518214
- UMLS CUI-2
- C1516048
Beschreibung
number of QOL instrument(s) completed
Datentyp
integer
Alias
- UMLS CUI-1
- C0034380
- UMLS CUI-2
- C0025663
Beschreibung
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Datentyp
text
Alias
- UMLS CUI-1
- C0392360
- UMLS CUI-2
- C2826217
Beschreibung
Other, specify (reason assessment was partially completed or not done)
Datentyp
text
Alias
- UMLS CUI-1
- C3845569
Beschreibung
Ccrr Module For Calgb: Qol Assessment Sumary 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.
C0348078 (UMLS CUI-2)
C2826693 (UMLS CUI-2)
C1691222 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
C0680022 (UMLS CUI-2)
C2981590 (UMLS CUI-2)
C0011008 (UMLS CUI-1)
C2082575 (UMLS CUI-2)
C1519246 (UMLS CUI-3)
C0420309 (UMLS CUI-2)
C0031809 (UMLS CUI-2)
C0376245 (UMLS CUI-1)
C3845569 (UMLS CUI-1)
C0023008 (UMLS CUI-2)
C25217 (NCI Thesaurus Property)
C0518214 (UMLS CUI-1)
C1516048 (UMLS CUI-2)
C0205197 (UMLS CUI-2)
C1272696 (UMLS CUI-1)
C0025663 (UMLS CUI-2)
C2826217 (UMLS CUI-2)
C0012634 (UMLS CUI-2)
C0035020 (UMLS CUI-3)
C1698058 (UMLS CUI-4)
C0600648 (UMLS CUI-2)
C0030705 (UMLS CUI-2)
C0205394 (UMLS CUI-2)