ID
802
Description
CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD 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=A50CE624-6F5F-37E3-E034-080020C9C0E0
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Versions (2)
- 8/26/12 8/26/12 -
- 5/20/15 5/20/15 - 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 NCT00024102 Transmittal - CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD FORM - 2044684v3.0
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
Dailycapecitabinedose
Data type
double
Description
Numberof500mgtabletsprescribedtobetakeneachday
Data type
double
Description
Numberof500mgtabletsissued
Data type
double
Description
Dateandtimetheelectronicdevicewasplacedonthevial
Data type
text
Description
Nameofthepersonwhofilledthevial
Data type
text
Description
Unnamed4
Description
DateandTimepillcountwasdone
Data type
text
Description
Howmany500mgtabletsreturned
Data type
double
Description
Dateandtimetheelectronicdevicewasremovedfromthevial
Data type
text
Description
Nameofthepersonwhoperformedthereturnpillcount
Data type
text
Description
CompletedBy
Data type
text
Description
DateCompleted
Data type
date
Description
Ccrr Module For Calgb: 49907 Capecitabine Drug Supply Record 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.
C0011008 (UMLS 2011AA ValueDomain)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)