ID

11674

Description

CALGB: BACKGROUND INFORMATION FORM 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 (2)
  1. 8/26/12 8/26/12 -
  2. 7/28/15 7/28/15 - Julian Varghese
Uploaded on

July 28, 2015

DOI

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License

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

English

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

1 forms  
General Administrative Data
Description

General 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

Amended data?
Description

Amendeddata?

Data type

text

Patient's Name
Description

Patient'sName

Data type

text

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

Patient details
Description

Patient details

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

IfyoudonotwishtoansweranyofthefollowingquestionspleasemarkanXhere.

Data type

text

Today's Date (M)
Description

Today'sDate

Data type

text

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

Whatisthehighestgradeyoufinishedinschool?

Data type

text

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

Whatisyourmaritalstatus?

Data type

text

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

Withwhomdoyoulive?

Data type

text

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
General Administrative Data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
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)
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
Patient details
IfyoudonotwishtoansweranyofthefollowingquestionspleasemarkanXhere.
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)
text
Item
What is the highest grade you finished in school? (3.)
text
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 2011AA)
CL Item
Some College (Some college)
CL Item
Junior College Degree (Junior college degree)
CL Item
College Degree (b.a./b.s.) (College degree (B.A./B.S.))
CL Item
Some Post-college Work (Some post-college work)
CL Item
Advanced Degree (Advanced degree)
Item
What is your marital status? (mark one with an X)
text
CL.3
Code List
What is your marital status? (mark one with an X)
CL Item
Single, Never Married (Single, never married)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS 2011AA)
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
Item
With whom do you live? (mark all that apply with an X)
text
CL.4
Code List
With whom do you live? (mark all that apply with an X)
CL Item
Spouse/partner (Spouse/Partner)
CL Item
Children Aged 18 Years Or Younger (Children aged 18 years or younger)
CL Item
Children Aged 19 Years Or Older (Children aged 19 years or older)
CL Item
Parent(s)/parent(s)-in-law (Parent(s)/Parent(s)-In-Law)
CL Item
Other Relative, Specify (Other relative, specify)
CL Item
Live Alone (Live alone)
CL Item
Other, Specify (Other, specify)
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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