ID
10237
Beschrijving
CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD 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=A50CE624-6F5F-37E3-E034-080020C9C0E0
Link
Trefwoorden
Versies (2)
- 26-08-12 26-08-12 -
- 20-05-15 20-05-15 - Martin Dugas
Geüploaded op
20 mei 2015
DOI
Voor een aanvraag inloggen.
Licentie
Creative Commons BY-NC 3.0 Legacy
Model Commentaren :
Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.
Itemgroep Commentaren voor :
Item Commentaren voor :
U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.
Breast Cancer DRUG SUPPLY NCT00024102 CALGB 49907
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 Statistical Center, Data Operations. 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.
Beschrijving
Drug Supply
Beschrijving
Dailycapecitabinedose
Datatype
float
Beschrijving
Numberof500mgtabletsprescribedtobetakeneachday
Datatype
float
Beschrijving
Numberof500mgtabletsissued
Datatype
float
Beschrijving
Dateandtimetheelectronicdevicewasplacedonthevial
Datatype
text
Beschrijving
Nameofthepersonwhofilledthevial
Datatype
text
Beschrijving
DateandTimepillcountwasdone
Datatype
text
Beschrijving
Howmany500mgtabletsreturned
Datatype
float
Beschrijving
Dateandtimetheelectronicdevicewasremovedfromthevial
Datatype
text
Beschrijving
Nameofthepersonwhoperformedthereturnpillcount
Datatype
text
Beschrijving
CompletedBy
Datatype
text
Beschrijving
DateCompleted
Datatype
date
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 Statistical Center, Data Operations. 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.
C0011008 (UMLS 2011AA ValueDomain)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)