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