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ID

10622

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-05-22 2015-05-22 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

3 juni 2015

DOI

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Licens

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
    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

    Amended data?
    Beskrivning

    Amendeddata?

    Datatyp

    text

    Patient's Name
    Beskrivning

    Patient'sName

    Datatyp

    text

    Responsible CRA
    Beskrivning

    ResponsibleCRA

    Datatyp

    text

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

    AssessmentNumber

    Datatyp

    float

    Participating Group
    Beskrivning

    ParticipatingGroup

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C17005 (undefined)
    UMLS 2011AA ObjectClass
    C1257890 (Population Group)
    SNOMED
    389109008
    LOINC
    LA12078-4
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    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

    Physical examination
    Beskrivning

    Physical examination

    Alias
    UMLS CUI-1
    C0031809 (Physical Examination)
    SNOMED
    5880005
    LOINC
    MTHU028014
    Mouth sores
    Beskrivning

    Mouthsores

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    Skin changes (such as redness or peeling) on hands or feet
    Beskrivning

    Skinchanges(suchasrednessorpeeling)onhandsorfeet

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    Swelling in hands or feet
    Beskrivning

    Swellinginhandsorfeet

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    Pain in hands or feet (OVERALL QUALITY OF LIFE)
    Beskrivning

    Paininhandsorfeet

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    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.)
    Beskrivning

    whatnumberwouldyousaybestdescribesyourcurrentstatofhealthoverjustthepasttwoweeks?

    Datatyp

    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)
    Beskrivning

    Atmost,howmuchtimewouldyouadviseyourfriendtogiveupoutof15yearsinordertoreturntofullhealth?

    Datatyp

    float

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

    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
    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
    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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