ID
802
Beskrivning
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
Länk
Nyckelord
Versioner (2)
- 2012-08-26 2012-08-26 -
- 2015-05-20 2015-05-20 - Martin Dugas
Uppladdad den
26 augusti 2012
DOI
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Licens
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.
Beskrivning
Unnamed2
Beskrivning
Patient'sName
Datatyp
text
Beskrivning
ParticipatingGroup
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beskrivning
PatientHospitalNumber
Datatyp
text
Beskrivning
ParticipatingGroupProtocolNo.
Datatyp
text
Beskrivning
MainMemberInstitution/Adjunct
Datatyp
text
Beskrivning
ParticipatingGroupPatientNo.
Datatyp
text
Beskrivning
Unnamed3
Beskrivning
Dailycapecitabinedose
Datatyp
double
Beskrivning
Numberof500mgtabletsprescribedtobetakeneachday
Datatyp
double
Beskrivning
Numberof500mgtabletsissued
Datatyp
double
Beskrivning
Dateandtimetheelectronicdevicewasplacedonthevial
Datatyp
text
Beskrivning
Nameofthepersonwhofilledthevial
Datatyp
text
Beskrivning
Unnamed4
Beskrivning
DateandTimepillcountwasdone
Datatyp
text
Beskrivning
Howmany500mgtabletsreturned
Datatyp
double
Beskrivning
Dateandtimetheelectronicdevicewasremovedfromthevial
Datatyp
text
Beskrivning
Nameofthepersonwhoperformedthereturnpillcount
Datatyp
text
Beskrivning
CompletedBy
Datatyp
text
Beskrivning
DateCompleted
Datatyp
date
Beskrivning
Ccrr Module For Calgb: 49907 Capecitabine Drug Supply Record 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 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)