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Description:

CALGB: SOCIAL SUPPORT FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF99D-12AE-2D64-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF99D-12AE-2D64-E034-080020C9C0E0

Keywords:

Quality of Life

Breast Neoplasms

Versions (2) ▾

12/18/14
3/23/15

Uploaded on:

March 23, 2015

DOI:

No DOI assigned. To request one pleaselog in.

License:

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00024102

English

Details

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.

StudyEvent: CALGB: SOCIAL SUPPORT FORM
1. 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.

Header

CALGB Patient ID

Date Completed (8.)

Yes (Yes)

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

Responsible CRA

Assessment Number (1.)

Social support

About how many close friends and close relatives do you have now (people you feel at ease with and can talk to about what is on your mind)? ([Number of close friends/relatives])

Someone to help if you were confined to bed (3.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone you can count on to listen to you when you need to talk (4.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to give you good advice about a crisis (5.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to take you to the doctor if you needed it (6.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone who shows you love and affection (7.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to have a good time with

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to give you information to help you understand a situation (9.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to confide in or talk to about yourself or your problems (10.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone who hugs you (11.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to get together with for relaxation (12.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to prepare your meals if you were unable to do it yourself (13.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone whose advice you really want (14.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to do things with to help you get your mind off things (15.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to help you with daily chores if you were sick (16.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to share your most private worries and fears with (17.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to turn to for suggestions about how to deal with a personal problem (18.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to do something enjoyable with (19.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone who understands your problems (20.)

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

Someone to love and make you feel wanted

None Of The Time (None of the Time)

A Little Of The Time (A Little of the Time)

Some Of The Time (Some of the Time)

Most Of The Time (Most of the Time)

All Of The Time (All of the Time)

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Contact

Institute of Medical Informatics
Director: Prof. Dr. Martin Dugas
Albert-Schweitzer-Campus 1, A11
48149 Münster, Germany
Email : imi@uni-muenster.de

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