Information:
Fel:
ID
10637
Beskrivning
CALGB: 49907 ADJUVANT TREATMENT SUMMARY FORM; Subset of Patients 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=A50CEAE3-8E50-387D-E034-080020C9C0E0
Länk
Nyckelord
Versioner (4)
- 2012-08-26 2012-08-26 -
- 2015-05-22 2015-05-22 -
- 2015-06-03 2015-06-03 -
- 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: 49907 ADJUVANT TREATMENT SUMMARY FORM; Subset of Patients 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.
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
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
CourseBeginDate
Item
Cycle start date
date
Cycleenddate
Item
Cycle end date (M)
text
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
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
CourseIdentification
Item
Current Cycle Number
text
BSA
Item
BSA
text
TotalDoseofDrugsforThisCycle
Item
Total Dose of Drugs for This Cycle (mg)
float
CL Item
Cyclophosphamide (Cyclophosphamide)
C405 (NCI Thesaurus)
C0010583 (UMLS 2011AA)
C0010583 (UMLS 2011AA)
CL Item
Methotrexate (Methotrexate)
C642 (NCI Thesaurus)
C0025677 (UMLS 2011AA)
C0025677 (UMLS 2011AA)
CL Item
Fluorouracil (Fluorouracil)
C505 (NCI Thesaurus)
C0016360 (UMLS 2011AA)
C0016360 (UMLS 2011AA)
CL Item
Adriamycin (Adriamycin)
CL Item
Capecitabine (Capecitabine)
C1794 (NCI Thesaurus)
C0671970 (UMLS 2011AA)
C0671970 (UMLS 2011AA)
Comments
Item
Comments
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date
Item Group
Ccrr Module For Calgb: 49907 Adjuvant Treatment Summary Form; Subset Of Patients