ID

11621

Description

CALGB: QOL ASSESSMENT SUMARY 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=A50D1BCF-4910-2EA3-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D1BCF-4910-2EA3-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: QOL ASSESSMENT SUMARY FORM NCT00024102

English

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.

1 forms  
CALGB Information
Description

CALGB Information

CALGB Form
Description

CALGB Form

Data type

text

Alias
UMLS CUI-1
C1516238
UMLS CUI-2
C0348078
CALGB Study No
Description

CALGB Study No

Data type

text

Alias
UMLS CUI-1
C1516238
UMLS CUI-2
C2826693
CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (M)
Description

Date Completed (M)

Data type

date

Alias
UMLS CUI-1
C1549507
Amended data?
Description

Amended data?

Data type

boolean

Alias
UMLS CUI-1
C1511726
UMLS CUI-2
C1691222
Interviewer or CRA
Description

InterviewerorCRA

Data type

text

Assessment Number
Description

AssessmentNumber

Data type

float

Patient data
Description

Patient data

Alias
UMLS CUI-1
C2707520
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

float

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

Participating Group Protocol No.

Data type

float

Alias
UMLS CUI-1
C0332037
Main Member Institution/Adjunct
Description

Main Member Institution/Adjunct

Data type

float

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

Participating Group Patient No.

Data type

float

Alias
UMLS CUI-1
C1830427
UMLS CUI-2
C2981590
Physical assessment
Description

Physical assessment

Alias
UMLS CUI-1
C0031809
Method of assessment (mark one with an X)
Description

Method of assessment (mark one with an X)

Data type

text

Alias
UMLS CUI-1
C2598110
date questionnaire was sent to patient (M)
Description

date questionnaire was sent to patient (M)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0011008
UMLS CUI-2
C2082575
UMLS CUI-3
C1519246
Number of attempts made to contact patient by telephone and/or mail
Description

Number of attempts made to contact patient by telephone and/or mail

Data type

integer

Alias
UMLS CUI-1
C0449788
UMLS CUI-2
C0420309
Language in which assessment was conducted (mark one with an X)
Description

Language in which assessment was conducted (mark one with an X)

Data type

text

Alias
UMLS CUI-1
C0424919
UMLS CUI-2
C0031809
Other, specify (language in which assessment was conducted)
Description

Other, specify (language in which assessment was conducted)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C3845569
UMLS CUI-2
C0023008
Quality of life assessment (mark one with an X)
Description

Quality of life assessment (mark one with an X)

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
NCI Thesaurus Property
C25217
UMLS CUI-1
C0518214
UMLS CUI-2
C1516048
number of QOL instrument(s) completed
Description

number of QOL instrument(s) completed

Data type

integer

Alias
UMLS CUI-1
C0034380
UMLS CUI-2
C0025663
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
Description

If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)

Data type

text

Alias
UMLS CUI-1
C0392360
UMLS CUI-2
C2826217
Other, specify (reason assessment was partially completed or not done)
Description

Other, specify (reason assessment was partially completed or not done)

Data type

text

Alias
UMLS CUI-1
C3845569
Ccrr Module For Calgb: Qol Assessment Sumary Form
Description

Ccrr Module For Calgb: Qol Assessment Sumary Form

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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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB Information
CALGBForm
Item
CALGB Form
text
C1516238 (UMLS CUI-1)
C0348078 (UMLS CUI-2)
CALGBStudyNo
Item
CALGB Study No
text
C1516238 (UMLS CUI-1)
C2826693 (UMLS CUI-2)
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
C1549507 (UMLS CUI-1)
Amendeddata?
Item
Amended data?
boolean
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
InterviewerorCRA
Item
Interviewer or CRA
text
AssessmentNumber
Item
Assessment Number
float
Item Group
Patient data
C2707520 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1257890 (UMLS CUI-1)
C0600091 (UMLS CUI-2)
PatientHospitalNumber
Item
Patient Hospital Number
float
C0421459 (UMLS CUI-1)
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
float
C0332037 (UMLS CUI-1)
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
float
C2607850 (UMLS CUI-1)
C0680022 (UMLS CUI-2)
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
float
C1830427 (UMLS CUI-1)
C2981590 (UMLS CUI-2)
Item Group
Physical assessment
C0031809 (UMLS CUI-1)
Item
Method of assessment (mark one with an X)
text
C2598110 (UMLS CUI-1)
CL.2
Code List
Method of assessment (mark one with an X)
CL Item
Interview In Clinic/hospital (Interview in clinic/hospital)
C0935589 (UMLS CUI-1)
CL Item
Self-report Questionnaire Administered In Clinic/hospital (Self-report questionnaire administered in clinic/hospital)
C0681906 (UMLS CUI-1)
CL Item
Telephone Interview (Telephone interview)
C0021823 (UMLS CUI-1)
CL Item
Mailed Questionnaire (Mailed questionnaire)
C0034394 (UMLS CUI-1)
datequestionnairewassenttopatient
Item
date questionnaire was sent to patient (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS CUI-1)
C2082575 (UMLS CUI-2)
C1519246 (UMLS CUI-3)
Numberofattemptsmadetocontactpatientbytelephoneand/ormail
Item
Number of attempts made to contact patient by telephone and/or mail
integer
C0449788 (UMLS CUI-1)
C0420309 (UMLS CUI-2)
Item
Language in which assessment was conducted (mark one with an X)
text
C0424919 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
CL.3
Code List
Language in which assessment was conducted (mark one with an X)
CL Item
English (English)
C43853 (NCI Thesaurus)
C0376245 (UMLS CUI-1)
CL Item
Spanish (Spanish)
C0037750 (UMLS CUI-1)
CL Item
French (French)
C0376246 (UMLS CUI-1)
CL Item
Other, Specify (Other, specify)
C3845569 (UMLS CUI-1)
Other,specify(languageinwhichassessmentwasconducted)
Item
Other, specify (language in which assessment was conducted)
text
C25704 (NCI Thesaurus ValueDomain)
C3845569 (UMLS CUI-1)
C0023008 (UMLS CUI-2)
Item
Quality of life assessment (mark one with an X)
text
C17047 (NCI Thesaurus ObjectClass)
C25217 (NCI Thesaurus Property)
C0518214 (UMLS CUI-1)
C1516048 (UMLS CUI-2)
CL.4
Code List
Quality of life assessment (mark one with an X)
CL Item
Completed (Completed)
C0205197 (UMLS CUI-1)
CL Item
Partially Completed (Partially completed)
C0728938 (UMLS CUI-1)
C0205197 (UMLS CUI-2)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
C1272696 (UMLS CUI-1)
numberofQOLinstrument(s)completed
Item
number of QOL instrument(s) completed
integer
C0034380 (UMLS CUI-1)
C0025663 (UMLS CUI-2)
Item
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
text
C0392360 (UMLS CUI-1)
C2826217 (UMLS CUI-2)
CL.5
Code List
If the assessment was partially completed or not done, indicate reason(s) below (mark all that apply with an X)
CL Item
Assessments Discontinued Due To Disease Progression Or Relapse, Per Protocol (Assessments discontinued due to disease progression or relapse, per protocol)
C0678226 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
C0035020 (UMLS CUI-3)
C1698058 (UMLS CUI-4)
CL Item
Patient Too Medically Ill (Patient too medically ill)
C0221423 (UMLS CUI-1)
CL Item
Interviewer Forgot To Call Patient Or Mail Questionnaire (Interviewer forgot to call patient or mail questionnaire)
CL Item
Patient Died (Patient died)
C1546956 (UMLS CUI-1)
CL Item
Patient Does Not Speak Language In Which Instruments Are Available (Patient does not speak language in which instruments are available)
CL Item
Patient Refuses (Patient refuses)
CL Item
Unable To Locate Patient (Unable to locate patient)
CL Item
Patient Does Not Understand Questions (Patient does not understand questions)
C0162340 (UMLS CUI-1)
C0600648 (UMLS CUI-2)
CL Item
Unable To Successfully Reach Patient (Unable to successfully reach patient)
C0560522 (UMLS CUI-1)
C0030705 (UMLS CUI-2)
CL Item
Patient Repeatedly Cancels Interview Due To Non-medical Reasons (Patient repeatedly cancels interview due to non-medical reasons)
CL Item
Patient Does Not Receive Questionnaire Or Repeatedly Loses Questionnaire And Does Not Wish To Be Interviewed By Telephone (Patient does not receive questionnaire or repeatedly loses questionnaire and does not wish to be interviewed by telephone)
CL Item
Other, Specify (Other, specify)
C1521902 (UMLS CUI-1)
C0205394 (UMLS CUI-2)
Other,specify(reasonassessmentwaspartiallycompletedornotdone)
Item
Other, specify (reason assessment was partially completed or not done)
text
C3845569 (UMLS CUI-1)
Item Group
Ccrr Module For Calgb: Qol Assessment Sumary Form
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