ID

6213

Description

CALGB: SOCIAL SUPPORT 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=A50BF99D-12AE-2D64-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50BF99D-12AE-2D64-E034-080020C9C0E0

Keywords

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 3/23/15 3/23/15 - Martin Dugas
Uploaded on

December 18, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00024102 Quality of Life - CALGB: SOCIAL SUPPORT FORM - 2041863v3.0

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 Data Management Center. 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.

Unnamed1
Description

Unnamed1

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (8.)
Description

DateCompleted

Data type

date

Amended data?
Description

Amendeddata?

Data type

text

Unnamed2
Description

Unnamed2

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

Unnamed3
Description

Unnamed3

Responsible CRA
Description

ResponsibleCRA

Data type

text

Assessment Number (1.)
Description

AssessmentNumber

Data type

double

Unnamed4
Description

Unnamed4

About how many close friends and close relatives do you have now (people you feel at ease with and can talk to about what is on your mind)? ([Number of close friends/relatives])
Description

Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?

Data type

double

Someone to help if you were confined to bed (3.)
Description

Someonetohelpifyouwereconfinedtobed

Data type

text

Someone you can count on to listen to you when you need to talk (4.)
Description

Someoneyoucancountontolistentoyouwhenyouneedtotalk

Data type

text

Someone to give you good advice about a crisis (5.)
Description

Someonetogiveyougoodadviceaboutacrisis

Data type

text

Someone to take you to the doctor if you needed it (6.)
Description

Someonetotakeyoutothedoctorifyouneededit

Data type

text

Someone who shows you love and affection (7.)
Description

Someonewhoshowsyouloveandaffection

Data type

text

Someone to have a good time with
Description

Someonetohaveagoodtimewith

Data type

text

Unnamed5
Description

Unnamed5

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (8.)
Description

DateCompleted

Data type

date

Unnamed6
Description

Unnamed6

Someone to give you information to help you understand a situation (9.)
Description

Someonetogiveyouinformationtohelpyouunderstandasituation

Data type

text

Someone to confide in or talk to about yourself or your problems (10.)
Description

Someonetoconfideinortalktoaboutyourselforyourproblems

Data type

text

Someone who hugs you (11.)
Description

Someonewhohugsyou

Data type

text

Someone to get together with for relaxation (12.)
Description

Someonetogettogetherwithforrelaxation

Data type

text

Someone to prepare your meals if you were unable to do it yourself (13.)
Description

Someonetoprepareyourmealsifyouwereunabletodoityourself

Data type

text

Someone whose advice you really want (14.)
Description

Someonewhoseadviceyoureallywant

Data type

text

Someone to do things with to help you get your mind off things (15.)
Description

Someonetodothingswithtohelpyougetyourmindoffthings

Data type

text

Someone to help you with daily chores if you were sick (16.)
Description

Someonetohelpyouwithdailychoresifyouweresick

Data type

text

Someone to share your most private worries and fears with (17.)
Description

Someonetoshareyourmostprivateworriesandfearswith

Data type

text

Someone to turn to for suggestions about how to deal with a personal problem (18.)
Description

Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem

Data type

text

Someone to do something enjoyable with (19.)
Description

Someonetodosomethingenjoyablewith

Data type

text

Someone who understands your problems (20.)
Description

Someonewhounderstandsyourproblems

Data type

text

Someone to love and make you feel wanted
Description

Someonetoloveandmakeyoufeelwanted

Data type

text

Ccrr Module For Calgb: Social Support Form
Description

Ccrr Module For Calgb: Social Support Form

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 Data Management Center. 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
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (8.)
date
Item
Amended data?
text
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
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
Unnamed3
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
double
Item Group
Unnamed4
Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Item
About how many close friends and close relatives do you have now (people you feel at ease with and can talk to about what is on your mind)? ([Number of close friends/relatives])
double
Item
Someone to help if you were confined to bed (3.)
text
Code List
Someone to help if you were confined to bed (3.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone you can count on to listen to you when you need to talk (4.)
text
Code List
Someone you can count on to listen to you when you need to talk (4.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to give you good advice about a crisis (5.)
text
Code List
Someone to give you good advice about a crisis (5.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to take you to the doctor if you needed it (6.)
text
Code List
Someone to take you to the doctor if you needed it (6.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who shows you love and affection (7.)
text
Code List
Someone who shows you love and affection (7.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to have a good time with
text
Code List
Someone to have a good time with
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item Group
Unnamed5
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (8.)
date
Item Group
Unnamed6
Item
Someone to give you information to help you understand a situation (9.)
text
Code List
Someone to give you information to help you understand a situation (9.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to confide in or talk to about yourself or your problems (10.)
text
Code List
Someone to confide in or talk to about yourself or your problems (10.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who hugs you (11.)
text
Code List
Someone who hugs you (11.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to get together with for relaxation (12.)
text
Code List
Someone to get together with for relaxation (12.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to prepare your meals if you were unable to do it yourself (13.)
text
Code List
Someone to prepare your meals if you were unable to do it yourself (13.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone whose advice you really want (14.)
text
Code List
Someone whose advice you really want (14.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to do things with to help you get your mind off things (15.)
text
Code List
Someone to do things with to help you get your mind off things (15.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to help you with daily chores if you were sick (16.)
text
Code List
Someone to help you with daily chores if you were sick (16.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to share your most private worries and fears with (17.)
text
Code List
Someone to share your most private worries and fears with (17.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to turn to for suggestions about how to deal with a personal problem (18.)
text
Code List
Someone to turn to for suggestions about how to deal with a personal problem (18.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to do something enjoyable with (19.)
text
Code List
Someone to do something enjoyable with (19.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone who understands your problems (20.)
text
Code List
Someone who understands your problems (20.)
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item
Someone to love and make you feel wanted
text
Code List
Someone to love and make you feel wanted
CL Item
None Of The Time (None of the Time)
CL Item
A Little Of The Time (A Little of the Time)
CL Item
Some Of The Time (Some of the Time)
CL Item
Most Of The Time (Most of the Time)
CL Item
All Of The Time (All of the Time)
Item Group
Ccrr Module For Calgb: Social Support Form

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