ID
736
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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- 26-08-12 26-08-12 -
- 08-07-15 08-07-15 -
- 08-07-15 08-07-15 -
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26 augustus 2012
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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.
Beschrijving
Unnamed2
Beschrijving
Patient'sName
Datatype
text
Beschrijving
ParticipatingGroup
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschrijving
PatientHospitalNumber
Datatype
text
Beschrijving
ParticipatingGroupProtocolNo.
Datatype
text
Beschrijving
MainMemberInstitution/Adjunct
Datatype
text
Beschrijving
ParticipatingGroupPatientNo.
Datatype
text
Beschrijving
Unnamed3
Beschrijving
Unnamed4
Beschrijving
Methodofassessment
Datatype
text
Beschrijving
datequestionnairewassenttopatient
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschrijving
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Datatype
double
Beschrijving
Languageinwhichassessmentwasconducted
Datatype
text
Beschrijving
Other,specify(languageinwhichassessmentwasconducted)
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
Beschrijving
Qualityoflifeassessment
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C17047
- UMLS 2011AA ObjectClass
- C0518214
- NCI Thesaurus Property
- C25217
- UMLS 2011AA Property
- C1516048
Beschrijving
numberofQOLinstrument(s)completed
Datatype
double
Beschrijving
Iftheassessmentwaspartiallycompletedornotdone,indicatereason(s)below
Datatype
text
Beschrijving
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Datatype
text
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.
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)