ID

6213

Beskrivning

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

Länk

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

Nyckelord

  1. 2014-12-18 2014-12-18 - Martin Dugas
  2. 2015-03-23 2015-03-23 - Martin Dugas
Uppladdad den

18 december 2014

DOI

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Licens

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
Beskrivning

Unnamed1

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBStudyNo

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Date Completed (8.)
Beskrivning

DateCompleted

Datatyp

date

Amended data?
Beskrivning

Amendeddata?

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Patient's Name
Beskrivning

Patient'sName

Datatyp

text

Participating Group
Beskrivning

ParticipatingGroup

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beskrivning

PatientHospitalNumber

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Main Member Institution/Adjunct
Beskrivning

MainMemberInstitution/Adjunct

Datatyp

text

Participating Group Patient No.
Beskrivning

ParticipatingGroupPatientNo.

Datatyp

text

Unnamed3
Beskrivning

Unnamed3

Responsible CRA
Beskrivning

ResponsibleCRA

Datatyp

text

Assessment Number (1.)
Beskrivning

AssessmentNumber

Datatyp

double

Unnamed4
Beskrivning

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])
Beskrivning

Abouthowmanyclosefriendsandcloserelativesdoyouhavenow(peopleyoufeelateasewithandcantalktoaboutwhatisonyourmind)?

Datatyp

double

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

Someonetohelpifyouwereconfinedtobed

Datatyp

text

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

Someoneyoucancountontolistentoyouwhenyouneedtotalk

Datatyp

text

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

Someonetogiveyougoodadviceaboutacrisis

Datatyp

text

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

Someonetotakeyoutothedoctorifyouneededit

Datatyp

text

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

Someonewhoshowsyouloveandaffection

Datatyp

text

Someone to have a good time with
Beskrivning

Someonetohaveagoodtimewith

Datatyp

text

Unnamed5
Beskrivning

Unnamed5

Patient's Name
Beskrivning

Patient'sName

Datatyp

text

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBStudyNo

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Date Completed (8.)
Beskrivning

DateCompleted

Datatyp

date

Unnamed6
Beskrivning

Unnamed6

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

Someonetogiveyouinformationtohelpyouunderstandasituation

Datatyp

text

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

Someonetoconfideinortalktoaboutyourselforyourproblems

Datatyp

text

Someone who hugs you (11.)
Beskrivning

Someonewhohugsyou

Datatyp

text

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

Someonetogettogetherwithforrelaxation

Datatyp

text

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

Someonetoprepareyourmealsifyouwereunabletodoityourself

Datatyp

text

Someone whose advice you really want (14.)
Beskrivning

Someonewhoseadviceyoureallywant

Datatyp

text

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

Someonetodothingswithtohelpyougetyourmindoffthings

Datatyp

text

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

Someonetohelpyouwithdailychoresifyouweresick

Datatyp

text

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

Someonetoshareyourmostprivateworriesandfearswith

Datatyp

text

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

Someonetoturntoforsuggestionsabouthowtodealwithapersonalproblem

Datatyp

text

Someone to do something enjoyable with (19.)
Beskrivning

Someonetodosomethingenjoyablewith

Datatyp

text

Someone who understands your problems (20.)
Beskrivning

Someonewhounderstandsyourproblems

Datatyp

text

Someone to love and make you feel wanted
Beskrivning

Someonetoloveandmakeyoufeelwanted

Datatyp

text

Ccrr Module For Calgb: Social Support Form
Beskrivning

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
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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