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
Lien
Mots-clés
Versions (2)
- 26/08/2012 26/08/2012 -
- 20/05/2015 20/05/2015 - Martin Dugas
Téléchargé le
26 août 2012
DOI
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Licence
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
Type de données
text
Description
ParticipatingGroup
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Type de données
text
Description
ParticipatingGroupProtocolNo.
Type de données
text
Description
MainMemberInstitution/Adjunct
Type de données
text
Description
ParticipatingGroupPatientNo.
Type de données
text
Description
Unnamed3
Description
Dailycapecitabinedose
Type de données
double
Description
Numberof500mgtabletsprescribedtobetakeneachday
Type de données
double
Description
Numberof500mgtabletsissued
Type de données
double
Description
Dateandtimetheelectronicdevicewasplacedonthevial
Type de données
text
Description
Nameofthepersonwhofilledthevial
Type de données
text
Description
Unnamed4
Description
DateandTimepillcountwasdone
Type de données
text
Description
Howmany500mgtabletsreturned
Type de données
double
Description
Dateandtimetheelectronicdevicewasremovedfromthevial
Type de données
text
Description
Nameofthepersonwhoperformedthereturnpillcount
Type de données
text
Description
CompletedBy
Type de données
text
Description
DateCompleted
Type de données
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)