ID
6183
Description
CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD 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=A50CE624-6F5F-37E3-E034-080020C9C0E0
Link
Keywords
Versions (2)
- 4/19/12 4/19/12 -
- 12/16/14 12/16/14 - Martin Dugas
Uploaded on
December 16, 2014
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102 Transmittal - CALGB 49907 CAPECITABINE DRUG SUPPLY RECORD FORM 2044684_v3_0
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 Statistical Center, Data Operations. 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.
Description
Medication
Alias
- UMLS CUI-1
- C0013227
Description
Dailycapecitabinedose
Data type
double
Description
Numberof500mgtabletsprescribedtobetakeneachday
Data type
double
Description
Numberof500mgtabletsissued
Data type
double
Description
Dateandtimetheelectronicdevicewasplacedonthevial
Data type
text
Description
Nameofthepersonwhofilledthevial
Data type
text
Description
DateandTimepillcountwasdone
Data type
text
Description
Howmany500mgtabletsreturned
Data type
double
Description
Dateandtimetheelectronicdevicewasremovedfromthevial
Data type
text
Description
Nameofthepersonwhoperformedthereturnpillcount
Data type
text
Description
CompletedBy
Data type
text
Description
DateCompleted
Data type
date
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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 Statistical Center, Data Operations. 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.
C0011008 (UMLS 2011AA ValueDomain)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)