ID

10462

Beskrivning

CALGB: CHANGES IN FUNCTION FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D6975-F5AD-3262-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D6975-F5AD-3262-E034-080020C9C0E0

Nyckelord

  1. 2014-12-18 2014-12-18 - Martin Dugas
  2. 2015-06-02 2015-06-02 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

2 juni 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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CALGB: CHANGES IN FUNCTION FORM

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.

CALGB clinical trial administrative data
Beskrivning

CALGB clinical trial administrative data

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBStudyNo

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Date Completed (M)
Beskrivning

DateCompleted

Datatyp

date

Patient's Name
Beskrivning

Patient'sName

Datatyp

text

Participating Group
Beskrivning

ParticipatingGroup

Datatyp

text

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

PatientHospitalNumber

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Main Member Institution/Adjunct
Beskrivning

MainMemberInstitution/Adjunct

Datatyp

text

Participating Group Patient No.
Beskrivning

ParticipatingGroupPatientNo.

Datatyp

text

Amended data?
Beskrivning

Amendeddata?

Datatyp

text

Assessment data
Beskrivning

Assessment data

Responsible CRA
Beskrivning

ResponsibleCRA

Datatyp

text

Assessment Number (1.)
Beskrivning

AssessmentNumber

Datatyp

float

Patient status assessment
Beskrivning

Patient status assessment

Has your physical condition gotten (2.)
Beskrivning

Hasyourphysicalconditiongotten

Datatyp

text

Has your emotional state gotten (3.)
Beskrivning

Hasyouremotionalstategotten

Datatyp

text

Has your ability to enjoy your social life gotten (4.)
Beskrivning

Hasyourabilitytoenjoyyoursociallifegotten

Datatyp

text

Has your overall quality of life gotten
Beskrivning

Hasyouroverallqualityoflifegotten

Datatyp

text

Ccrr Module For Calgb: Changes In Function Form
Beskrivning

Ccrr Module For Calgb: Changes In Function Form

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.

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
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
Item
Amended data?
text
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Assessment data
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
float
Item Group
Patient status assessment
Item
Has your physical condition gotten (2.)
text
Code List
Has your physical condition gotten (2.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your emotional state gotten (3.)
text
Code List
Has your emotional state gotten (3.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your ability to enjoy your social life gotten (4.)
text
Code List
Has your ability to enjoy your social life gotten (4.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your overall quality of life gotten
text
Code List
Has your overall quality of life gotten
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item Group
Ccrr Module For Calgb: Changes In Function Form

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