ID

736

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

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D1BCF-4910-2EA3-E034-080020C9C0E0

Keywords

  1. 8/26/12 8/26/12 -
  2. 7/8/15 7/8/15 -
  3. 7/8/15 7/8/15 -
Uploaded on

August 26, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00024102 Quality of Life - CALGB: QOL ASSESSMENT SUMARY FORM - 2037828v3.0

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.

Unnamed1
Description

Unnamed1

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (M)
Description

DateCompleted

Data type

date

Amended data?
Description

Amendeddata?

Data type

text

Unnamed2
Description

Unnamed2

Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Unnamed3
Description

Unnamed3

Interviewer or CRA
Description

InterviewerorCRA

Data type

text

Assessment Number
Description

AssessmentNumber

Data type

double

Unnamed4
Description

Unnamed4

Method of assessment (mark one with an X)
Description

Methodofassessment

Data type

text

date questionnaire was sent to patient (M)
Description

datequestionnairewassenttopatient

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Number of attempts made to contact patient by telephone and/or mail
Description

Numberofattemptsmadetocontactpatientbytelephoneand/ormail

Data type

double

Language in which assessment was conducted (mark one with an X)
Description

Languageinwhichassessmentwasconducted

Data type

text

Other, specify (language in which assessment was conducted)
Description

Other,specify(languageinwhichassessmentwasconducted)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Quality of life assessment (mark one with an X)
Description

Qualityoflifeassessment

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25217
UMLS 2011AA Property
C1516048
number of QOL instrument(s) completed
Description

numberofQOLinstrument(s)completed

Data type

double

If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Description

Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below

Data type

text

Other, specify (reason assessment was partially completed or not done)
Description

Other,specify(reasonassessmentwaspartiallycompletedornotdone)

Data type

text

Ccrr Module For Calgb: Qol Assessment Sumary Form
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.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
Item
Amended data?
text
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Unnamed3
InterviewerorCRA
Item
Interviewer or CRA
text
AssessmentNumber
Item
Assessment Number
double
Item Group
Unnamed4
Item
Method of assessment (mark one with an X)
text
Code List
Method of assessment (mark one with an X)
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
CL Item
Telephone Interview (Telephone interview)
CL Item
Mailed Questionnaire (Mailed questionnaire)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
double
Item
Language in which assessment was conducted (mark one with an X)
text
Code List
Language in which assessment was conducted (mark one with an X)
CL Item
English (English)
C43853 (NCI Thesaurus)
C1556083 (UMLS 2011AA)
CL Item
Spanish (Spanish)
CL Item
French (French)
CL Item
Other, Specify (Other, specify)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify (language in which assessment was conducted)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Quality of life assessment (mark one with an X)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
Code List
Quality of life assessment (mark one with an X)
CL Item
Completed (Completed)
CL Item
Partially Completed (Partially completed)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
double
Item
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
text
Code List
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
CL Item
Patient Too Medically Ill (Patient too medically ill)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Died (Patient died)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Patient Refuses (Patient refuses)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify (reason assessment was partially completed or not done)
text
Item Group
Ccrr Module For Calgb: Qol Assessment Sumary Form

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