Description:

CALGB: Y-ME COUNSELOR TELEPHONE CONTACT 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=A50CF1AD-5DEE-3887-E034-080020C9C0E0

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CF1AD-5DEE-3887-E034-080020C9C0E0
Keywords:
Versions (2)
  1. 12/12/14 12/12/14 - Martin Dugas
  2. 4/13/21 4/13/21 - Dr. rer. medic Philipp Neuhaus
Uploaded on:

April 13, 2021

DOI:
To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00024102 Quality of Life - CALGB: Y-ME COUNSELOR TELEPHONE CONTACT FORM - 2044777v3.0

English
Details

INSTRUCTIONS: The Y-ME counselor will complete and submit this form as required by the protocol. Information in the upper right box muse 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. Retain a copy for your records and send the original to the CALGB Data Management Center.

1 forms  
General Information
Patient enrolled in 49907 (1.)
Session with (mark one with an X)
Topics Discussed (mark all that apply with an X)
Patient asked the following about this clinical trial (mark all that apply with an X)
3 more items in the detailed view.
Consent Form (mark all that apply with an X)
Specific protocol-related issues (mark all that apply with an X)
Telephone Interview
What were the patient's concerns about participating in this clinical trial? (mark all that apply)
14 more items in the detailed view.
Most Important (patient's concerns about participating in this trial)
14 more items in the detailed view.
2nd Most Important (patient's concerns about participating in this trial)
14 more items in the detailed view.
3rd Most Important (patient's concerns about participating in this trial)
14 more items in the detailed view.
What was the outcome at the end of the call? (mark all that apply with an X)
4 more items in the detailed view.
Back to the top of the page

Similar models

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial