ID

11610

Description

CALGB: BACKGROUND INFORMATION FORM NCT00041119 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=A50BF263-C019-2D60-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF263-C019-2D60-E034-080020C9C0E0

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 7/8/15 7/8/15 -
  3. 7/8/15 7/8/15 -
Uploaded on

July 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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CALGB: BACKGROUND INFORMATION FORM NCT00041119

English

THANK YOU VERY MUCH FOR YOUR VOLUNTARY PARTICIPATION! PLEASE RETURN TO THE PERSON WHO HANDED YOU THIS FORM.

1 forms  
Cancer and Leukemia Group B Data
Description

Cancer and Leukemia Group B Data

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended data?
Description

Amended data?

Data type

boolean

Patient demographics
Description

Patient demographics

Alias
UMLS CUI-1
C1955348
Patient's Name
Description

Patient's Name

Data type

text

Alias
UMLS CUI-1
C1299487
Participating Group
Description

Participating Group

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
NCI Thesaurus Property
C25364
UMLS CUI-1
C1257890
UMLS CUI-2
C0600091
Patient Hospital Number
Description

Patient Hospital Number

Data type

text

Alias
UMLS CUI-1
C0421459
Participating Group Protocol No.
Description

Participating Group Protocol No.

Data type

text

Alias
UMLS CUI-1
C0008971
UMLS CUI-2
C0237753
Main Member Institution/Adjunct
Description

Main Member Institution/Adjunct

Data type

text

Alias
UMLS CUI-1
C0680022
UMLS CUI-2
C2607850
Participating Group Patient No.
Description

Participating Group Patient No.

Data type

text

Alias
UMLS CUI-1
C1830427
UMLS CUI-2
C0441833
Social status
Description

Social status

Alias
UMLS CUI-1
C0699806
If you do not wish to answer any of the following questions please mark an X here. (1.)
Description

If you do not wish to answer any of the following questions please mark an X here. (1.)

Data type

text

Today's Date (M)
Description

Today's Date (M)

Data type

date

What is the highest grade you finished in school? (3.)
Description

Education level

Data type

text

Alias
UMLS CUI-1
C3166592
What is your marital status? (mark one with an X)
Description

What is your marital status? (mark one with an X)

Data type

text

Alias
UMLS CUI-1
C0024819
With whom do you live? (mark all that apply with an X)
Description

With whom do you live? (mark all that apply with an X)

Data type

text

Alias
UMLS CUI-1
C0020052
UMLS CUI-2
C0018677
Other relative, specify (with whom you live)
Description

Otherrelative,specify(withwhomyoulive)

Data type

text

Other, specify (with whom you live) (5.)
Description

Other,specify(withwhomyoulive)

Data type

text

What is your current employment status? (mark all that apply with an X)
Description

Whatisyourcurrentemploymentstatus?

Data type

text

Other, specify (current employment status)
Description

Other,specify(currentemploymentstatus)

Data type

text

Ccrr Module For Calgb: Background Information Form
Description

Ccrr Module For Calgb: Background Information Form

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Similar models

THANK YOU VERY MUCH FOR YOUR VOLUNTARY PARTICIPATION! PLEASE RETURN TO THE PERSON WHO HANDED YOU THIS FORM.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Cancer and Leukemia Group B Data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Amendeddata?
Item
Amended data?
boolean
Item Group
Patient demographics
C1955348 (UMLS CUI-1)
Patient's Name
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
Participating Group
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
Patient Hospital Number
Item
Patient Hospital Number
text
C0421459 (UMLS CUI-1)
Participating Group Protocol No.
Item
Participating Group Protocol No.
text
C0008971 (UMLS CUI-1)
C0237753 (UMLS CUI-2)
Main Member Institution/Adjunct
Item
Main Member Institution/Adjunct
text
C0680022 (UMLS CUI-1)
C2607850 (UMLS CUI-2)
Participating Group Patient No.
Item
Participating Group Patient No.
text
C1830427 (UMLS CUI-1)
C0441833 (UMLS CUI-2)
Item Group
Social status
C0699806 (UMLS CUI-1)
If you do not wish to answer any of the following questions please mark an X here. (1.)
Item
If you do not wish to answer any of the following questions please mark an X here. (1.)
text
Today'sDate
Item
Today's Date (M)
date
Item
What is the highest grade you finished in school? (3.)
text
C3166592 (UMLS CUI-1)
CL.2
Code List
What is the highest grade you finished in school? (3.)
CL Item
1-8 Grades (1-8 grades)
CL Item
9-11 Grades (9-11 grades)
CL Item
High School Graduate (High School graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS CUI-1)
CL Item
Some College (Some college)
C1883065 (UMLS CUI-1)
CL Item
Junior College Degree (Junior college degree)
C0681414 (UMLS CUI-1)
CL Item
College Degree (b.a./b.s.) (College degree (B.A./B.S.))
C1552034 (UMLS CUI-1)
CL Item
Some Post-college Work (Some post-college work)
CL Item
Advanced Degree (Advanced degree)
C0556960 (UMLS CUI-1)
Item
What is your marital status? (mark one with an X)
text
C0024819 (UMLS CUI-1)
CL.3
Code List
What is your marital status? (mark one with an X)
CL Item
Single, Never Married (Single, never married)
C0037179 (UMLS CUI-1)
C0027952 (UMLS CUI-2)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
C0555047 (UMLS CUI-1)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS CUI-1)
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
C0086170 (UMLS CUI-1)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS CUI-1)
Item
With whom do you live? (mark all that apply with an X)
text
C0020052 (UMLS CUI-1)
C0018677 (UMLS CUI-2)
CL.4
Code List
With whom do you live? (mark all that apply with an X)
CL Item
Spouse/partner (Spouse/Partner)
C0162409 (UMLS CUI-1)
CL Item
Children Aged 18 Years Or Younger (Children aged 18 years or younger)
C0008059 (UMLS CUI-1)
C0026193 (UMLS CUI-2)
CL Item
Children Aged 19 Years Or Older (Children aged 19 years or older)
C0008059 (UMLS CUI-1)
CL Item
Parent(s)/parent(s)-in-law (Parent(s)/Parent(s)-In-Law)
CL Item
Other Relative, Specify (Other relative, specify)
C0080103 (UMLS CUI-1)
CL Item
Live Alone (Live alone)
C0439044 (UMLS CUI-1)
CL Item
Other, Specify (Other, specify)
C1707811 (UMLS CUI-1)
C3840932 (UMLS CUI-2)
Otherrelative,specify(withwhomyoulive)
Item
Other relative, specify (with whom you live)
text
Other,specify(withwhomyoulive)
Item
Other, specify (with whom you live) (5.)
text
Item
What is your current employment status? (mark all that apply with an X)
text
CL.5
Code List
What is your current employment status? (mark all that apply with an X)
CL Item
Employed 32 Hours Or More Per Week (Employed 32 hours or more per week)
CL Item
Employed Less Than 32 Hours Per (Employed less than 32 hours per)
CL Item
Full-time Student (Full-time student)
CL Item
Part-time Student (Part-time student)
CL Item
Homemaker (Homemaker)
C0555052 (NCI Metathesaurus)
CL Item
On Medical Leave (On medical leave)
CL Item
Disabled (Disabled)
C63367 (NCI Thesaurus)
C1880351 (UMLS 2011AA)
CL Item
Unemployed (Unemployed)
C0425086 (NCI Metathesaurus)
CL Item
Retired (Retired)
CL Item
Other, Specify (Other, specify)
Other,specify(currentemploymentstatus)
Item
Other, specify (current employment status)
text
Item Group
Ccrr Module For Calgb: Background Information Form
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