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