ID

11674

Descripción

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

Palabras clave

  1. 26/8/12 26/8/12 -
  2. 28/7/15 28/7/15 - Julian Varghese
Subido en

28 de julio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy

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CALGB: BACKGROUND INFORMATION FORM

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

General Administrative Data
Descripción

General Administrative Data

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

Amendeddata?

Tipo de datos

text

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Patient details
Descripción

Patient details

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

IfyoudonotwishtoansweranyofthefollowingquestionspleasemarkanXhere.

Tipo de datos

text

Today's Date (M)
Descripción

Today'sDate

Tipo de datos

text

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

Whatisthehighestgradeyoufinishedinschool?

Tipo de datos

text

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

Whatisyourmaritalstatus?

Tipo de datos

text

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

Withwhomdoyoulive?

Tipo de datos

text

Other relative, specify (with whom you live)
Descripción

Otherrelative,specify(withwhomyoulive)

Tipo de datos

text

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

Other,specify(withwhomyoulive)

Tipo de datos

text

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

Whatisyourcurrentemploymentstatus?

Tipo de datos

text

Other, specify (current employment status)
Descripción

Other,specify(currentemploymentstatus)

Tipo de datos

text

Ccrr Module For Calgb: Background Information Form
Descripción

Ccrr Module For Calgb: Background Information Form

Similar models

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

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
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
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
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
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
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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