ID
11620
Descrizione
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
collegamento
Keywords
versioni (3)
- 26/08/12 26/08/12 -
- 08/07/15 08/07/15 -
- 08/07/15 08/07/15 -
Caricato su
8 luglio 2015
DOI
Per favore, per richiedere un accesso.
Licenza
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.
Descrizione
Patient data
Alias
- UMLS CUI-1
- C2707520
Descrizione
Patient's Name
Tipo di dati
text
Alias
- UMLS CUI-1
- C1299487
Descrizione
Participating Group
Tipo di dati
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- NCI Thesaurus Property
- C25364
- UMLS CUI-1
- C1257890
- UMLS CUI-2
- C0600091
Descrizione
Patient Hospital Number
Tipo di dati
float
Alias
- UMLS CUI-1
- C0421459
Descrizione
Participating Group Protocol No.
Tipo di dati
float
Alias
- UMLS CUI-1
- C0332037
Descrizione
Main Member Institution/Adjunct
Tipo di dati
float
Alias
- UMLS CUI-1
- C2607850
- UMLS CUI-2
- C0680022
Descrizione
Participating Group Patient No.
Tipo di dati
float
Alias
- UMLS CUI-1
- C1830427
- UMLS CUI-2
- C2981590
Descrizione
Physical assessment
Alias
- UMLS CUI-1
- C0031809
Descrizione
Method of assessment (mark one with an X)
Tipo di dati
text
Alias
- UMLS CUI-1
- C2598110
Descrizione
date questionnaire was sent to patient (M)
Tipo di dati
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
- UMLS CUI-2
- C2082575
- UMLS CUI-3
- C1519246
Descrizione
Number of attempts made to contact patient by telephone and/or mail
Tipo di dati
integer
Alias
- UMLS CUI-1
- C0449788
- UMLS CUI-2
- C0420309
Descrizione
Language in which assessment was conducted (mark one with an X)
Tipo di dati
text
Alias
- UMLS CUI-1
- C0424919
- UMLS CUI-2
- C0031809
Descrizione
Other, specify (language in which assessment was conducted)
Tipo di dati
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C3845569
- UMLS CUI-2
- C0023008
Descrizione
Quality of life assessment (mark one with an X)
Tipo di dati
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- NCI Thesaurus Property
- C25217
- UMLS CUI-1
- C0518214
- UMLS CUI-2
- C1516048
Descrizione
number of QOL instrument(s) completed
Tipo di dati
integer
Alias
- UMLS CUI-1
- C0034380
- UMLS CUI-2
- C0025663
Descrizione
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Tipo di dati
text
Alias
- UMLS CUI-1
- C0392360
- UMLS CUI-2
- C2826217
Descrizione
Other, specify (reason assessment was partially completed or not done)
Tipo di dati
text
Alias
- UMLS CUI-1
- C3845569
Descrizione
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)