ID
6213
Beschrijving
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
Trefwoorden
Versies (2)
- 18-12-14 18-12-14 - Martin Dugas
- 23-03-15 23-03-15 - Martin Dugas
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18 december 2014
DOI
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Licentie
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.
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Unnamed2
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Patient'sName
Datatype
text
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ParticipatingGroup
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
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PatientHospitalNumber
Datatype
text
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ParticipatingGroupProtocolNo.
Datatype
text
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MainMemberInstitution/Adjunct
Datatype
text
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ParticipatingGroupPatientNo.
Datatype
text
Beschrijving
Unnamed3
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Unnamed4
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Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Datatype
double
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Someonetohelpifyouwereconfinedtobed
Datatype
text
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Someoneyoucancountontolistentoyouwhenyouneedtotalk
Datatype
text
Beschrijving
Someonetogiveyougoodadviceaboutacrisis
Datatype
text
Beschrijving
Someonetotakeyoutothedoctorifyouneededit
Datatype
text
Beschrijving
Someonewhoshowsyouloveandaffection
Datatype
text
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Someonetohaveagoodtimewith
Datatype
text
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Unnamed5
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Unnamed6
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Someonetogiveyouinformationtohelpyouunderstandasituation
Datatype
text
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Someonetoconfideinortalktoaboutyourselforyourproblems
Datatype
text
Beschrijving
Someonewhohugsyou
Datatype
text
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Someonetogettogetherwithforrelaxation
Datatype
text
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Someonetoprepareyourmealsifyouwereunabletodoityourself
Datatype
text
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Someonewhoseadviceyoureallywant
Datatype
text
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Someonetodothingswithtohelpyougetyourmindoffthings
Datatype
text
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Someonetohelpyouwithdailychoresifyouweresick
Datatype
text
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Someonetoshareyourmostprivateworriesandfearswith
Datatype
text
Beschrijving
Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem
Datatype
text
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Someonetodosomethingenjoyablewith
Datatype
text
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Someonewhounderstandsyourproblems
Datatype
text
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Someonetoloveandmakeyoufeelwanted
Datatype
text
Beschrijving
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)