ID
6213
Descripción
CALGB: SOCIAL SUPPORT 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=A50BF99D-12AE-2D64-E034-080020C9C0E0
Link
Palabras clave
Versiones (2)
- 18/12/14 18/12/14 - Martin Dugas
- 23/3/15 23/3/15 - Martin Dugas
Subido en
18 de diciembre de 2014
DOI
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Licencia
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102 Quality of Life - CALGB: SOCIAL SUPPORT FORM - 2041863v3.0
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.
Descripción
Unnamed2
Descripción
Patient'sName
Tipo de datos
text
Descripción
ParticipatingGroup
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Descripción
PatientHospitalNumber
Tipo de datos
text
Descripción
ParticipatingGroupProtocolNo.
Tipo de datos
text
Descripción
MainMemberInstitution/Adjunct
Tipo de datos
text
Descripción
ParticipatingGroupPatientNo.
Tipo de datos
text
Descripción
Unnamed3
Descripción
Unnamed4
Descripción
Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Tipo de datos
double
Descripción
Someonetohelpifyouwereconfinedtobed
Tipo de datos
text
Descripción
Someoneyoucancountontolistentoyouwhenyouneedtotalk
Tipo de datos
text
Descripción
Someonetogiveyougoodadviceaboutacrisis
Tipo de datos
text
Descripción
Someonetotakeyoutothedoctorifyouneededit
Tipo de datos
text
Descripción
Someonewhoshowsyouloveandaffection
Tipo de datos
text
Descripción
Someonetohaveagoodtimewith
Tipo de datos
text
Descripción
Unnamed5
Descripción
Unnamed6
Descripción
Someonetogiveyouinformationtohelpyouunderstandasituation
Tipo de datos
text
Descripción
Someonetoconfideinortalktoaboutyourselforyourproblems
Tipo de datos
text
Descripción
Someonewhohugsyou
Tipo de datos
text
Descripción
Someonetogettogetherwithforrelaxation
Tipo de datos
text
Descripción
Someonetoprepareyourmealsifyouwereunabletodoityourself
Tipo de datos
text
Descripción
Someonewhoseadviceyoureallywant
Tipo de datos
text
Descripción
Someonetodothingswithtohelpyougetyourmindoffthings
Tipo de datos
text
Descripción
Someonetohelpyouwithdailychoresifyouweresick
Tipo de datos
text
Descripción
Someonetoshareyourmostprivateworriesandfearswith
Tipo de datos
text
Descripción
Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem
Tipo de datos
text
Descripción
Someonetodosomethingenjoyablewith
Tipo de datos
text
Descripción
Someonewhounderstandsyourproblems
Tipo de datos
text
Descripción
Someonetoloveandmakeyoufeelwanted
Tipo de datos
text
Descripción
Ccrr Module For Calgb: Social Support 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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)