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:

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 3/23/15 3/23/15 - Martin Dugas
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March 23, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102

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.

Amended data?
Social support
Someone to help if you were confined to bed (3.)
Someone you can count on to listen to you when you need to talk (4.)
Someone to give you good advice about a crisis (5.)
Someone to take you to the doctor if you needed it (6.)
Someone who shows you love and affection (7.)
Someone to have a good time with
Someone to give you information to help you understand a situation (9.)
Someone to confide in or talk to about yourself or your problems (10.)
Someone who hugs you (11.)
Someone to get together with for relaxation (12.)
Someone to prepare your meals if you were unable to do it yourself (13.)
Someone whose advice you really want (14.)
Someone to do things with to help you get your mind off things (15.)
Someone to help you with daily chores if you were sick (16.)
Someone to share your most private worries and fears with (17.)
Someone to turn to for suggestions about how to deal with a personal problem (18.)
Someone to do something enjoyable with (19.)
Someone who understands your problems (20.)
Someone to love and make you feel wanted

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