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