ID
736
Descripción
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
Palabras clave
Versiones (3)
- 26/8/12 26/8/12 -
- 8/7/15 8/7/15 -
- 8/7/15 8/7/15 -
Subido en
26 de agosto de 2012
DOI
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Licencia
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.
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
Methodofassessment
Tipo de datos
text
Descripción
datequestionnairewassenttopatient
Tipo de datos
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Descripción
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Tipo de datos
double
Descripción
Languageinwhichassessmentwasconducted
Tipo de datos
text
Descripción
Other,specify(languageinwhichassessmentwasconducted)
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
Descripción
Qualityoflifeassessment
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- UMLS 2011AA ObjectClass
- C0518214
- NCI Thesaurus Property
- C25217
- UMLS 2011AA Property
- C1516048
Descripción
numberofQOLinstrument(s)completed
Tipo de datos
double
Descripción
Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below
Tipo de datos
text
Descripción
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Tipo de datos
text
Descripción
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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C1556083 (UMLS 2011AA)
C1527021 (UMLS 2011AA ValueDomain)
C0518214 (UMLS 2011AA ObjectClass)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)