ID

10083

Beschrijving

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

Link

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

Trefwoorden

Versies (2)
  1. 18-12-14 18-12-14 - Martin Dugas
  2. 24-03-15 24-03-15 - Martin Dugas
Geüploaded op

24 maart 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102

Engels

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 Formulieren  
Header
Beschrijving

Header

CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBStudyNo

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Date Completed (6.)
Beschrijving

DateCompleted

Datatype

date

Amended data?
Beschrijving

Amended data?

Datatype

boolean

Alias
UMLS CUI-1
C0680532
Patient's Name
Beschrijving

Patient'sName

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

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

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Adjunct

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientNo.

Datatype

text

Responsible CRA
Beschrijving

ResponsibleCRA

Datatype

text

Assessment Number (1.)
Beschrijving

AssessmentNumber

Datatype

float

Compliance behavior
Beschrijving

Compliance behavior

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

ThebenefitsofmycancertreatmentoutweighthedifficultiesIhaveinfollowingit.

Datatype

text

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

IbelievethattakingmycancermedicationistoomuchtroubleforwhatIwillgetoutofit.

Datatype

text

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

Becausetheschedulefortakingmycancermedicationistoodifficult,itisnotbeworthfollowingit.

Datatype

text

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

Takingmycancermedicationisbetterformethannottakingit.

Datatype

text

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

Takingmycancermedicationishelpingmetobehealthy.

Datatype

text

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

IwillbejustashealthyevenifIwerenottakingmycancermedication

Datatype

text

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

Ibelievethatmycancertreatmentishelpingtocuremeofcancer

Datatype

text

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

Itishardtobelievethatmycancertreatmentishelpingme

Datatype

text

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

Lotsofthingsaregettinginthewayoffollowingtheschedulefortakingmycancermedication

Datatype

text

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

Ineedmoreassistanceinordertofollowtheschedulefortakingmycancermedication.

Datatype

text

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

IamgettingthehelpIneedtofollowmycancermedicationschedule.

Datatype

text

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

Iamabletodealwithanyproblemsintakingmycancermedication.

Datatype

text

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

Thesideeffectsofmycancermedicationdisruptmynormalactivities.

Datatype

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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