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
Lien
Mots-clés
Versions (2)
- 18/12/2014 18/12/2014 - Martin Dugas
- 23/03/2015 23/03/2015 - Martin Dugas
Téléchargé le
18 décembre 2014
DOI
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Licence
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
Type de données
text
Description
ParticipatingGroup
Type de données
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Type de données
text
Description
ParticipatingGroupProtocolNo.
Type de données
text
Description
MainMemberInstitution/Adjunct
Type de données
text
Description
ParticipatingGroupPatientNo.
Type de données
text
Description
Unnamed3
Description
Unnamed4
Description
Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?
Type de données
double
Description
Someonetohelpifyouwereconfinedtobed
Type de données
text
Description
Someoneyoucancountontolistentoyouwhenyouneedtotalk
Type de données
text
Description
Someonetogiveyougoodadviceaboutacrisis
Type de données
text
Description
Someonetotakeyoutothedoctorifyouneededit
Type de données
text
Description
Someonewhoshowsyouloveandaffection
Type de données
text
Description
Someonetohaveagoodtimewith
Type de données
text
Description
Unnamed5
Description
Patient'sName
Type de données
text
Description
CALGBForm
Type de données
text
Description
CALGBStudyNo
Type de données
text
Description
CALGBPatientID
Type de données
text
Description
DateCompleted
Type de données
date
Description
Unnamed6
Description
Someonetogiveyouinformationtohelpyouunderstandasituation
Type de données
text
Description
Someonetoconfideinortalktoaboutyourselforyourproblems
Type de données
text
Description
Someonewhohugsyou
Type de données
text
Description
Someonetogettogetherwithforrelaxation
Type de données
text
Description
Someonetoprepareyourmealsifyouwereunabletodoityourself
Type de données
text
Description
Someonewhoseadviceyoureallywant
Type de données
text
Description
Someonetodothingswithtohelpyougetyourmindoffthings
Type de données
text
Description
Someonetohelpyouwithdailychoresifyouweresick
Type de données
text
Description
Someonetoshareyourmostprivateworriesandfearswith
Type de données
text
Description
Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem
Type de données
text
Description
Someonetodosomethingenjoyablewith
Type de données
text
Description
Someonewhounderstandsyourproblems
Type de données
text
Description
Someonetoloveandmakeyoufeelwanted
Type de données
text
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.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)