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ID

10622

Description

CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM NCT00024102 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=A50CCBC1-A49F-3714-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CCBC1-A49F-3714-E034-080020C9C0E0

Keywords

  1. 8/26/12 8/26/12 -
  2. 5/22/15 5/22/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    CALGB: PHYSICAL PROBLEMS DUE TO CANCER TREATMENT FORM 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.

    CALGB clinical trial administrative data
    Description

    CALGB clinical trial administrative data

    CALGB Form
    Description

    CALGBForm

    Data type

    text

    CALGB Study No
    Description

    CALGBStudyNo

    Data type

    text

    CALGB Patient ID
    Description

    CALGBPatientID

    Data type

    text

    Date Completed (M)
    Description

    DateCompleted

    Data type

    date

    Amended data?
    Description

    Amendeddata?

    Data type

    text

    Patient's Name
    Description

    Patient'sName

    Data type

    text

    Responsible CRA
    Description

    ResponsibleCRA

    Data type

    text

    Assessment Number (ADDITIONAL PHYSICAL PROBLEMS DUE TO CANCER TREATMENT [SIDE EFFECTS])
    Description

    AssessmentNumber

    Data type

    float

    Participating Group
    Description

    ParticipatingGroup

    Data type

    text

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

    PatientHospitalNumber

    Data type

    text

    Participating Group Protocol No.
    Description

    ParticipatingGroupProtocolNo.

    Data type

    text

    Main Member Institution/Adjunct
    Description

    MainMemberInstitution/Adjunct

    Data type

    text

    Participating Group Patient No.
    Description

    ParticipatingGroupPatientNo.

    Data type

    text

    Physical examination
    Description

    Physical examination

    Alias
    UMLS CUI-1
    C0031809
    Mouth sores
    Description

    Mouthsores

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Skin changes (such as redness or peeling) on hands or feet
    Description

    Skinchanges(suchasrednessorpeeling)onhandsorfeet

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Swelling in hands or feet
    Description

    Swellinginhandsorfeet

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Pain in hands or feet (OVERALL QUALITY OF LIFE)
    Description

    Paininhandsorfeet

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    what number would you say best describes your current stat of health over just the past two weeks? (3. Imagine that a friend of yours is expected to live for 15 years with the same quality of live as you have now. Suppose treatment could restore your friend to full health, but would shorten his/her life.)
    Description

    whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?

    Data type

    float

    At most, how much time would you advise your friend to give up out of 15 years in order to return to full health? (months)
    Description

    Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?

    Data type

    float

    Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment Form
    Description

    Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment 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
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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
    Item
    Amended data?
    text
    Code List
    Amended data?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Patient'sName
    Item
    Patient's Name
    text
    ResponsibleCRA
    Item
    Responsible CRA
    text
    AssessmentNumber
    Item
    Assessment Number (ADDITIONAL PHYSICAL PROBLEMS DUE TO CANCER TREATMENT [SIDE EFFECTS])
    float
    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 Group
    Physical examination
    C0031809 (UMLS CUI-1)
    Item
    Mouth sores
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Mouth sores
    CL Item
    Not At All (Not at All)
    C91213 (NCI Thesaurus)
    CL Item
    A Little (A Little)
    CL Item
    Quite A Bit (Quite a Bit)
    C91216 (NCI Thesaurus)
    CL Item
    Very Much (Very Much)
    C91217 (NCI Thesaurus)
    Item
    Skin changes (such as redness or peeling) on hands or feet
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Skin changes (such as redness or peeling) on hands or feet
    CL Item
    Not At All (Not at All)
    C91213 (NCI Thesaurus)
    CL Item
    A Little (A Little)
    CL Item
    Quite A Bit (Quite a Bit)
    C91216 (NCI Thesaurus)
    CL Item
    Very Much (Very Much)
    C91217 (NCI Thesaurus)
    Item
    Swelling in hands or feet
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Swelling in hands or feet
    CL Item
    Not At All (Not at All)
    C91213 (NCI Thesaurus)
    CL Item
    A Little (A Little)
    CL Item
    Quite A Bit (Quite a Bit)
    C91216 (NCI Thesaurus)
    CL Item
    Very Much (Very Much)
    C91217 (NCI Thesaurus)
    Item
    Pain in hands or feet (OVERALL QUALITY OF LIFE)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Pain in hands or feet (OVERALL QUALITY OF LIFE)
    CL Item
    Not At All (Not at All)
    C91213 (NCI Thesaurus)
    CL Item
    A Little (A Little)
    CL Item
    Quite A Bit (Quite a Bit)
    C91216 (NCI Thesaurus)
    CL Item
    Very Much (Very Much)
    C91217 (NCI Thesaurus)
    whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?
    Item
    what number would you say best describes your current stat of health over just the past two weeks? (3. Imagine that a friend of yours is expected to live for 15 years with the same quality of live as you have now. Suppose treatment could restore your friend to full health, but would shorten his/her life.)
    float
    Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?
    Item
    At most, how much time would you advise your friend to give up out of 15 years in order to return to full health? (months)
    float
    Item Group
    Ccrr Module For Calgb: Physical Problems Due To Cancer Treatment Form

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