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
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Versions (2)
- 12/18/14 12/18/14 - Martin Dugas
- 3/23/15 3/23/15 - Martin Dugas
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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.
Description
Unnamed2
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
MainMemberInstitution/Adjunct
Data type
text
Description
ParticipatingGroupPatientNo.
Data type
text
Description
Unnamed3
Description
Unnamed4
Description
Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Data type
double
Description
Someonetohelpifyouwereconfinedtobed
Data type
text
Description
Someoneyoucancountontolistentoyouwhenyouneedtotalk
Data type
text
Description
Someonetogiveyougoodadviceaboutacrisis
Data type
text
Description
Someonetotakeyoutothedoctorifyouneededit
Data type
text
Description
Someonewhoshowsyouloveandaffection
Data type
text
Description
Someonetohaveagoodtimewith
Data type
text
Description
Unnamed5
Description
Unnamed6
Description
Someonetogiveyouinformationtohelpyouunderstandasituation
Data type
text
Description
Someonetoconfideinortalktoaboutyourselforyourproblems
Data type
text
Description
Someonewhohugsyou
Data type
text
Description
Someonetogettogetherwithforrelaxation
Data type
text
Description
Someonetoprepareyourmealsifyouwereunabletodoityourself
Data type
text
Description
Someonewhoseadviceyoureallywant
Data type
text
Description
Someonetodothingswithtohelpyougetyourmindoffthings
Data type
text
Description
Someonetohelpyouwithdailychoresifyouweresick
Data type
text
Description
Someonetoshareyourmostprivateworriesandfearswith
Data type
text
Description
Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem
Data type
text
Description
Someonetodosomethingenjoyablewith
Data type
text
Description
Someonewhounderstandsyourproblems
Data type
text
Description
Someonetoloveandmakeyoufeelwanted
Data type
text
Description
Ccrr Module For Calgb: Social Support Form
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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 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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)