ID

10083

Description

CALGB: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) 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=A50CC350-FC34-364B-E034-080020C9C0E0

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CC350-FC34-364B-E034-080020C9C0E0

Mots-clés

Versions (2)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 24/03/2015 24/03/2015 - Martin Dugas
Téléchargé le

24 mars 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102

Anglais

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.

1 Formulaires  
Header
Description

Header

CALGB Form
Description

CALGBForm

Type de données

text

CALGB Study No
Description

CALGBStudyNo

Type de données

text

CALGB Patient ID
Description

CALGBPatientID

Type de données

text

Date Completed (6.)
Description

DateCompleted

Type de données

date

Amended data?
Description

Amended data?

Type de données

boolean

Alias
UMLS CUI-1
C0680532
Patient's Name
Description

Patient'sName

Type de données

text

Participating Group
Description

ParticipatingGroup

Type de données

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Type de données

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Type de données

text

Responsible CRA
Description

ResponsibleCRA

Type de données

text

Assessment Number (1.)
Description

AssessmentNumber

Type de données

float

Compliance behavior
Description

Compliance behavior

Alias
UMLS CUI-1
C1321605
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
Description

ThebenefitsofmycancertreatmentoutweighthedifficultiesIhaveinfollowingit.

Type de données

text

I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
Description

IbelievethattakingmycancermedicationistoomuchtroubleforwhatIwillgetoutofit.

Type de données

text

Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
Description

Becausetheschedulefortakingmycancermedicationistoodifficult,itisnotbeworthfollowingit.

Type de données

text

Taking my cancer medication is better for me than not taking it. (5.)
Description

Takingmycancermedicationisbetterformethannottakingit.

Type de données

text

Taking my cancer medication is helping me to be healthy.
Description

Takingmycancermedicationishelpingmetobehealthy.

Type de données

text

I will be just as healthy even if I were not taking my cancer medication. (7.)
Description

IwillbejustashealthyevenifIwerenottakingmycancermedication

Type de données

text

I believe that my cancer treatment is helping to cure me of cancer. (8.)
Description

Ibelievethatmycancertreatmentishelpingtocuremeofcancer

Type de données

text

It is hard to believe that my cancer treatment is helping me. (9.)
Description

Itishardtobelievethatmycancertreatmentishelpingme

Type de données

text

Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
Description

Lotsofthingsaregettinginthewayoffollowingtheschedulefortakingmycancermedication

Type de données

text

I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
Description

Ineedmoreassistanceinordertofollowtheschedulefortakingmycancermedication.

Type de données

text

I am getting the help I need to follow my cancer medication schedule. (12.)
Description

IamgettingthehelpIneedtofollowmycancermedicationschedule.

Type de données

text

I am able to deal with any problems in taking my cancer medication. (13.)
Description

Iamabletodealwithanyproblemsintakingmycancermedication.

Type de données

text

The side effects of my cancer medication disrupt my normal activities.
Description

Thesideeffectsofmycancermedicationdisruptmynormalactivities.

Type de données

text

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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 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.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (6.)
date
Amended data
Item
Amended data?
boolean
C0680532 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
float
Item Group
Compliance behavior
C1321605 (UMLS CUI-1)
Item
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
text
CL.2
Code List
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
text
CL.2
Code List
I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
text
CL.2
Code List
Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
Taking my cancer medication is better for me than not taking it. (5.)
text
CL.2
Code List
Taking my cancer medication is better for me than not taking it. (5.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
Taking my cancer medication is helping me to be healthy.
text
CL.2
Code List
Taking my cancer medication is helping me to be healthy.
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I will be just as healthy even if I were not taking my cancer medication. (7.)
text
CL.2
Code List
I will be just as healthy even if I were not taking my cancer medication. (7.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I believe that my cancer treatment is helping to cure me of cancer. (8.)
text
CL.2
Code List
I believe that my cancer treatment is helping to cure me of cancer. (8.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
It is hard to believe that my cancer treatment is helping me. (9.)
text
CL.2
Code List
It is hard to believe that my cancer treatment is helping me. (9.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
text
CL.2
Code List
Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
text
CL.2
Code List
I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I am getting the help I need to follow my cancer medication schedule. (12.)
text
CL.2
Code List
I am getting the help I need to follow my cancer medication schedule. (12.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
I am able to deal with any problems in taking my cancer medication. (13.)
text
CL.2
Code List
I am able to deal with any problems in taking my cancer medication. (13.)
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
Item
The side effects of my cancer medication disrupt my normal activities.
text
CL.2
Code List
The side effects of my cancer medication disrupt my normal activities.
CL Item
Strongly Disagree (1)
C3641826 (UMLS CUI-1)
CL Item
Disagree (2)
C3641828 (UMLS CUI-1)
CL Item
Neither Agree Nor Disagree (3)
C3843223 (UMLS CUI-1)
CL Item
Agree (4)
C3641827 (UMLS CUI-1)
CL Item
Strongly Agree (5)
C3642483 (UMLS CUI-1)
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