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Informatie:
Fout:
ID
6213
Beschrijving
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
Trefwoorden
Versies (2)
- 18-12-14 18-12-14 - Martin Dugas
- 23-03-15 23-03-15 - Martin Dugas
Geüploaded op
18 december 2014
DOI
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Licentie
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.
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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.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (8.)
date
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
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
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
double
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
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
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
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
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)
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)
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)
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
Someone to give you information to help you understand a situation (9.)
text
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
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)
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)
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
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)
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
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
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
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
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)
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)
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)
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)