ID

6183

Descrizione

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

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CE624-6F5F-37E3-E034-080020C9C0E0

Keywords

  1. 19/04/12 19/04/12 -
  2. 16/12/14 16/12/14 - Martin Dugas
Caricato su

16 dicembre 2014

DOI

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Licenza

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.

General information
Descrizione

General information

Alias
UMLS CUI-1
C1508263
CALGB Form
Descrizione

CALGBForm

Tipo di dati

text

CALGB Study No
Descrizione

CALGBStudyNo

Tipo di dati

text

CALGB Patient ID
Descrizione

CALGBPatientID

Tipo di dati

text

Last date of reporting cycle (M)
Descrizione

Lastdateofreportingcycle

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Amended data?
Descrizione

Amendeddata?

Tipo di dati

text

Patient's Name
Descrizione

Patient'sName

Tipo di dati

text

Participating Group
Descrizione

ParticipatingGroup

Tipo di dati

text

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

PatientHospitalNumber

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Main Member Institution/Adjunct
Descrizione

MainMemberInstitution/Adjunct

Tipo di dati

text

Participating Group Patient No.
Descrizione

ParticipatingGroupPatientNo.

Tipo di dati

text

Medication
Descrizione

Medication

Alias
UMLS CUI-1
C0013227
Daily capecitabine dose (mg)
Descrizione

Dailycapecitabinedose

Tipo di dati

double

Number of 500 mg tablets prescribed to be taken each day
Descrizione

Numberof500mgtabletsprescribedtobetakeneachday

Tipo di dati

double

Number of 500 mg tablets issued
Descrizione

Numberof500mgtabletsissued

Tipo di dati

double

Date and time the electronic device was placed on the vial (Use a military-24 hour clock)
Descrizione

Dateandtimetheelectronicdevicewasplacedonthevial

Tipo di dati

text

Name of the person who filled the vial (Use a military-24 hour clock)
Descrizione

Nameofthepersonwhofilledthevial

Tipo di dati

text

Date and Time pill count was done
Descrizione

DateandTimepillcountwasdone

Tipo di dati

text

How many 500 mg tablets returned (Exact pill count)
Descrizione

Howmany500mgtabletsreturned

Tipo di dati

double

Date and time the electronic device was removed from the vial (Use a military-24 hour clock)
Descrizione

Dateandtimetheelectronicdevicewasremovedfromthevial

Tipo di dati

text

Name of the person who performed the return pill count
Descrizione

Nameofthepersonwhoperformedthereturnpillcount

Tipo di dati

text

Completed By (Print or Type Name)
Descrizione

CompletedBy

Tipo di dati

text

Date Completed (M)
Descrizione

DateCompleted

Tipo di dati

date

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 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.

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
General information
C1508263 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Lastdateofreportingcycle
Item
Last date of reporting cycle (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
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
Medication
C0013227 (UMLS CUI-1)
Dailycapecitabinedose
Item
Daily capecitabine dose (mg)
double
Numberof500mgtabletsprescribedtobetakeneachday
Item
Number of 500 mg tablets prescribed to be taken each day
double
Numberof500mgtabletsissued
Item
Number of 500 mg tablets issued
double
Dateandtimetheelectronicdevicewasplacedonthevial
Item
Date and time the electronic device was placed on the vial (Use a military-24 hour clock)
text
Nameofthepersonwhofilledthevial
Item
Name of the person who filled the vial (Use a military-24 hour clock)
text
DateandTimepillcountwasdone
Item
Date and Time pill count was done
text
Howmany500mgtabletsreturned
Item
How many 500 mg tablets returned (Exact pill count)
double
Dateandtimetheelectronicdevicewasremovedfromthevial
Item
Date and time the electronic device was removed from the vial (Use a military-24 hour clock)
text
Nameofthepersonwhoperformedthereturnpillcount
Item
Name of the person who performed the return pill count
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date

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