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.

1 forms

StudyEvent: CALGB: SOCIAL SUPPORT FORM
1. 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

Unnamed1

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

Amendeddata?

Item

Amended data?

text

CL.1

Code List

Amended data?

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

Unnamed2

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

Unnamed3

Item Group

Unnamed3

ResponsibleCRA

Item

Responsible CRA

text

AssessmentNumber

Item

Assessment Number (1.)

double

Unnamed4

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

Someonetohelpifyouwereconfinedtobed

Item

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

text

CL.2

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)

Someoneyoucancountontolistentoyouwhenyouneedtotalk

Item

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

text

CL.3

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)

Someonetogiveyougoodadviceaboutacrisis

Item

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

text

CL.4

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)

Someonetotakeyoutothedoctorifyouneededit

Item

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

text

CL.5

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)

Someonewhoshowsyouloveandaffection

Item

Someone who shows you love and affection (7.)

text

CL.6

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)

Someonetohaveagoodtimewith

Item

Someone to have a good time with

text

CL.7

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)

Unnamed5

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

Unnamed6

Item Group

Unnamed6

Someonetogiveyouinformationtohelpyouunderstandasituation

Item

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

text

CL.8

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)

Someonetoconfideinortalktoaboutyourselforyourproblems

Item

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

text

CL.9

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)

Someonewhohugsyou

Item

Someone who hugs you (11.)

text

CL.10

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)

Someonetogettogetherwithforrelaxation

Item

Someone to get together with for relaxation (12.)

text

CL.11

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)

Someonetoprepareyourmealsifyouwereunabletodoityourself

Item

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

text

CL.12

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)

Someonewhoseadviceyoureallywant

Item

Someone whose advice you really want (14.)

text

CL.13

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)

Someonetodothingswithtohelpyougetyourmindoffthings

Item

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

text

CL.14

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)

Someonetohelpyouwithdailychoresifyouweresick

Item

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

text

CL.15

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)

Someonetoshareyourmostprivateworriesandfearswith

Item

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

text

CL.16

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)

Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem

Item

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

text

CL.17

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)

Someonetodosomethingenjoyablewith

Item

Someone to do something enjoyable with (19.)

text

CL.18

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)

Someonewhounderstandsyourproblems

Item

Someone who understands your problems (20.)

text

CL.19

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)

Someonetoloveandmakeyoufeelwanted

Item

Someone to love and make you feel wanted

text

CL.20

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)

CCRR MODULE

Item Group

Ccrr Module For Calgb: Social Support Form

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