ID
801
Description
CALGB: 40101 TREATMENT SUMMARY SUBSET FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0
Link
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Versions (2)
- 8/26/12 8/26/12 -
- 4/24/15 4/24/15 - Martin Dugas
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00041119 Treatment - CALGB: 40101 TREATMENT SUMMARY SUBSET FORM - 2037407v3.0
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 Statistical Center, Data Operations. 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.
Description
Unnamed2
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
MainMemberInstitution/Adjunct
Data type
text
Description
ParticipatingGroupPatientNo.
Data type
text
Description
Unnamed3
Description
Unnamed4
Description
Totaldosageforthiscycle,Doxorubicin
Data type
text
Description
Totaldosageforthiscycle,Cyclophosphamide
Data type
text
Description
Totaldosageforthiscycle,Paclitaxel
Data type
text
Description
Doseadjustments
Data type
text
Description
Reasonforadjustment
Data type
text
Description
Specify(reasonforadjustment)
Data type
text
Description
Unnamed5
Description
Ccrr Module For Calgb: 40101 Treatment Summary Subset Form
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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 Statistical Center, Data Operations. 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)
C0237753 (UMLS 2011AA ValueDomain)
C0392756 (UMLS 2011AA)
C0205394 (UMLS 2011AA)