ID
11620
Descripción
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
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Versiones (3)
- 26/8/12 26/8/12 -
- 8/7/15 8/7/15 -
- 8/7/15 8/7/15 -
Subido en
8 de julio de 2015
DOI
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Licencia
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.
Descripción
Patient data
Alias
- UMLS CUI-1
- C2707520
Descripción
Patient's Name
Tipo de datos
text
Alias
- UMLS CUI-1
- C1299487
Descripción
Participating Group
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1257890
- UMLS CUI-2
- C0600091
Descripción
Patient Hospital Number
Tipo de datos
float
Alias
- UMLS CUI-1
- C0421459
Descripción
Participating Group Protocol No.
Tipo de datos
float
Alias
- UMLS CUI-1
- C0332037
Descripción
Main Member Institution/Adjunct
Tipo de datos
float
Alias
- UMLS CUI-1
- C2607850
- UMLS CUI-2
- C0680022
Descripción
Participating Group Patient No.
Tipo de datos
float
Alias
- UMLS CUI-1
- C1830427
- UMLS CUI-2
- C2981590
Descripción
Physical assessment
Alias
- UMLS CUI-1
- C0031809
Descripción
Method of assessment (mark one with an X)
Tipo de datos
text
Alias
- UMLS CUI-1
- C2598110
Descripción
date questionnaire was sent to patient (M)
Tipo de datos
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
- UMLS CUI-2
- C2082575
- UMLS CUI-3
- C1519246
Descripción
Number of attempts made to contact patient by telephone and/or mail
Tipo de datos
integer
Alias
- UMLS CUI-1
- C0449788
- UMLS CUI-2
- C0420309
Descripción
Language in which assessment was conducted (mark one with an X)
Tipo de datos
text
Alias
- UMLS CUI-1
- C0424919
- UMLS CUI-2
- C0031809
Descripción
Other, specify (language in which assessment was conducted)
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C3845569
- UMLS CUI-2
- C0023008
Descripción
Quality of life assessment (mark one with an X)
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- NCI Thesaurus Property
- C25217
- UMLS CUI-1
- C0518214
- UMLS CUI-2
- C1516048
Descripción
number of QOL instrument(s) completed
Tipo de datos
integer
Alias
- UMLS CUI-1
- C0034380
- UMLS CUI-2
- C0025663
Descripción
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Tipo de datos
text
Alias
- UMLS CUI-1
- C0392360
- UMLS CUI-2
- C2826217
Descripción
Other, specify (reason assessment was partially completed or not done)
Tipo de datos
text
Alias
- UMLS CUI-1
- C3845569
Descripción
Ccrr Module For Calgb: Qol Assessment Sumary 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.
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)