CALGB: QOL ASSESSMENT SUMARY FORM NCT00024102

CALGB: QOL ASSESSMENT SUMARY FORM NCT00024102 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

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.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB Information
CALGBForm
Item
CALGB Form
text
C1516238 (UMLS CUI-1)
C0348078 (UMLS CUI-2)
CALGBStudyNo
Item
CALGB Study No
text
C1516238 (UMLS CUI-1)
C2826693 (UMLS CUI-2)
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
C1549507 (UMLS CUI-1)
Amendeddata?
Item
Amended data?
boolean
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
InterviewerorCRA
Item
Interviewer or CRA
text
AssessmentNumber
Item
Assessment Number
float
Item Group
Patient data
C2707520 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
PatientHospitalNumber
Item
Patient Hospital Number
float
C0421459 (UMLS CUI-1)
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
float
C0332037 (UMLS CUI-1)
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
float
C2607850 (UMLS CUI-1)
C0680022 (UMLS CUI-2)
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
float
C1830427 (UMLS CUI-1)
C2981590 (UMLS CUI-2)
Item Group
Physical assessment
C0031809 (UMLS CUI-1)
Item
Method of assessment (mark one with an X)
text
C2598110 (UMLS CUI-1)
Code List
Method of assessment (mark one with an X)
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
C0935589 (UMLS CUI-1)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
C0681906 (UMLS CUI-1)
CL Item
Telephone Interview (Telephone interview)
C0021823 (UMLS CUI-1)
CL Item
Mailed Questionnaire (Mailed questionnaire)
C0034394 (UMLS CUI-1)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS CUI-1)
C2082575 (UMLS CUI-2)
C1519246 (UMLS CUI-3)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
integer
C0449788 (UMLS CUI-1)
C0420309 (UMLS CUI-2)
Item
Language in which assessment was conducted (mark one with an X)
text
C0424919 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
Code List
Language in which assessment was conducted (mark one with an X)
CL Item
English (English)
C43853 (NCI Thesaurus)
C0376245 (UMLS CUI-1)
CL Item
Spanish (Spanish)
C0037750 (UMLS CUI-1)
CL Item
French (French)
C0376246 (UMLS CUI-1)
CL Item
Other, Specify (Other, specify)
C3845569 (UMLS CUI-1)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify (language in which assessment was conducted)
text
C25704 (NCI Thesaurus ValueDomain)
C3845569 (UMLS CUI-1)
C0023008 (UMLS CUI-2)
Item
Quality of life assessment (mark one with an X)
text
C17047 (NCI Thesaurus ObjectClass)
C25217 (NCI Thesaurus Property)
C0518214 (UMLS CUI-1)
C1516048 (UMLS CUI-2)
Code List
Quality of life assessment (mark one with an X)
CL Item
Completed (Completed)
C0205197 (UMLS CUI-1)
CL Item
Partially Completed (Partially completed)
C0728938 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
C1272696 (UMLS CUI-1)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
integer
C0034380 (UMLS CUI-1)
C0025663 (UMLS CUI-2)
Item
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
text
C0392360 (UMLS CUI-1)
C2826217 (UMLS CUI-2)
Code List
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
C0678226 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
C0035020 (UMLS CUI-3)
C1698058 (UMLS CUI-4)
CL Item
Patient Too Medically Ill (Patient too medically ill)
C0221423 (UMLS CUI-1)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Died (Patient died)
C1546956 (UMLS CUI-1)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Patient Refuses (Patient refuses)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
C0162340 (UMLS CUI-1)
C0600648 (UMLS CUI-2)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
C0560522 (UMLS CUI-1)
C0030705 (UMLS CUI-2)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
C1521902 (UMLS CUI-1)
C0205394 (UMLS CUI-2)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify (reason assessment was partially completed or not done)
text
C3845569 (UMLS CUI-1)
Item Group
Ccrr Module For Calgb: Qol Assessment Sumary Form

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