ID
11620
Beskrivning
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
Länk
Nyckelord
Versioner (3)
- 2012-08-26 2012-08-26 -
- 2015-07-08 2015-07-08 -
- 2015-07-08 2015-07-08 -
Uppladdad den
8 juli 2015
DOI
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Licens
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.
Beskrivning
Patient data
Alias
- UMLS CUI-1
- C2707520
Beskrivning
Patient's Name
Datatyp
text
Alias
- UMLS CUI-1
- C1299487
Beskrivning
Participating Group
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1257890
- UMLS CUI-2
- C0600091
Beskrivning
Patient Hospital Number
Datatyp
float
Alias
- UMLS CUI-1
- C0421459
Beskrivning
Participating Group Protocol No.
Datatyp
float
Alias
- UMLS CUI-1
- C0332037
Beskrivning
Main Member Institution/Adjunct
Datatyp
float
Alias
- UMLS CUI-1
- C2607850
- UMLS CUI-2
- C0680022
Beskrivning
Participating Group Patient No.
Datatyp
float
Alias
- UMLS CUI-1
- C1830427
- UMLS CUI-2
- C2981590
Beskrivning
Physical assessment
Alias
- UMLS CUI-1
- C0031809
Beskrivning
Method of assessment (mark one with an X)
Datatyp
text
Alias
- UMLS CUI-1
- C2598110
Beskrivning
date questionnaire was sent to patient (M)
Datatyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
- UMLS CUI-2
- C2082575
- UMLS CUI-3
- C1519246
Beskrivning
Number of attempts made to contact patient by telephone and/or mail
Datatyp
integer
Alias
- UMLS CUI-1
- C0449788
- UMLS CUI-2
- C0420309
Beskrivning
Language in which assessment was conducted (mark one with an X)
Datatyp
text
Alias
- UMLS CUI-1
- C0424919
- UMLS CUI-2
- C0031809
Beskrivning
Other, specify (language in which assessment was conducted)
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C3845569
- UMLS CUI-2
- C0023008
Beskrivning
Quality of life assessment (mark one with an X)
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- NCI Thesaurus Property
- C25217
- UMLS CUI-1
- C0518214
- UMLS CUI-2
- C1516048
Beskrivning
number of QOL instrument(s) completed
Datatyp
integer
Alias
- UMLS CUI-1
- C0034380
- UMLS CUI-2
- C0025663
Beskrivning
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Datatyp
text
Alias
- UMLS CUI-1
- C0392360
- UMLS CUI-2
- C2826217
Beskrivning
Other, specify (reason assessment was partially completed or not done)
Datatyp
text
Alias
- UMLS CUI-1
- C3845569
Beskrivning
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)