ID

6217

Description

CALGB: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) 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=A50CC350-FC34-364B-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CC350-FC34-364B-E034-080020C9C0E0

Keywords

Versions (2)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 3/24/15 3/24/15 - Martin Dugas
Uploaded on

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: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) - 2044166v3.0

English

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  
Unnamed1
Description

Unnamed1

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (6.)
Description

DateCompleted

Data type

date

Amended data?
Description

Amendeddata?

Data type

text

Unnamed2
Description

Unnamed2

Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

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

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Unnamed3
Description

Unnamed3

Responsible CRA
Description

ResponsibleCRA

Data type

text

Assessment Number (1.)
Description

AssessmentNumber

Data type

double

Unnamed4
Description

Unnamed4

The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
Description

ThebenefitsofmycancertreatmentoutweighthedifficultiesIhaveinfollowingit.

Data type

text

I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
Description

IbelievethattakingmycancermedicationistoomuchtroubleforwhatIwillgetoutofit.

Data type

text

Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
Description

Becausetheschedulefortakingmycancermedicationistoodifficult,itisnotbeworthfollowingit.

Data type

text

Taking my cancer medication is better for me than not taking it. (5.)
Description

Takingmycancermedicationisbetterformethannottakingit.

Data type

text

Taking my cancer medication is helping me to be healthy.
Description

Takingmycancermedicationishelpingmetobehealthy.

Data type

text

Unnamed5
Description

Unnamed5

Patient's Name
Description

Patient'sName

Data type

text

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBStudyNo

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Date Completed (6.)
Description

DateCompleted

Data type

date

Unnamed6
Description

Unnamed6

I will be just as healthy even if I were not taking my cancer medication. (7.)
Description

IwillbejustashealthyevenifIwerenottakingmycancermedication.

Data type

text

I believe that my cancer treatment is helping to cure me of cancer. (8.)
Description

Ibelievethatmycancertreatmentishelpingtocuremeofcancer.

Data type

text

It is hard to believe that my cancer treatment is helping me. (9.)
Description

Itishardtobelievethatmycancertreatmentishelpingme.

Data type

text

Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
Description

Lotsofthingsaregettinginthewayoffollowingtheschedulefortakingmycancermedication.

Data type

text

I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
Description

Ineedmoreassistanceinordertofollowtheschedulefortakingmycancermedication.

Data type

text

I am getting the help I need to follow my cancer medication schedule. (12.)
Description

IamgettingthehelpIneedtofollowmycancermedicationschedule.

Data type

text

I am able to deal with any problems in taking my cancer medication. (13.)
Description

Iamabletodealwithanyproblemsintakingmycancermedication.

Data type

text

The side effects of my cancer medication disrupt my normal activities.
Description

Thesideeffectsofmycancermedicationdisruptmynormalactivities.

Data type

text

Ccrr Module For Calgb: Adherence Questionnaire Form (follow-up)
Description

Ccrr Module For Calgb: Adherence Questionnaire Form (follow-up)

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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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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 (6.)
date
Item
Amended data?
text
CL.1
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
Item
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
text
CL.2
Code List
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
text
CL.3
Code List
I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
text
CL.4
Code List
Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
Taking my cancer medication is better for me than not taking it. (5.)
text
CL.5
Code List
Taking my cancer medication is better for me than not taking it. (5.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
Taking my cancer medication is helping me to be healthy.
text
CL.6
Code List
Taking my cancer medication is helping me to be healthy.
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
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 (6.)
date
Item Group
Unnamed6
Item
I will be just as healthy even if I were not taking my cancer medication. (7.)
text
CL.7
Code List
I will be just as healthy even if I were not taking my cancer medication. (7.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
I believe that my cancer treatment is helping to cure me of cancer. (8.)
text
CL.8
Code List
I believe that my cancer treatment is helping to cure me of cancer. (8.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
It is hard to believe that my cancer treatment is helping me. (9.)
text
CL.9
Code List
It is hard to believe that my cancer treatment is helping me. (9.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
text
CL.10
Code List
Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
text
CL.11
Code List
I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
I am getting the help I need to follow my cancer medication schedule. (12.)
text
CL.12
Code List
I am getting the help I need to follow my cancer medication schedule. (12.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
I am able to deal with any problems in taking my cancer medication. (13.)
text
CL.13
Code List
I am able to deal with any problems in taking my cancer medication. (13.)
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item
The side effects of my cancer medication disrupt my normal activities.
text
CL.14
Code List
The side effects of my cancer medication disrupt my normal activities.
CL Item
Strongly Disagree (Strongly Disagree)
CL Item
Disagree (Disagree)
CL Item
Neither Agree Nor Disagree (Neither Agree Nor Disagree)
CL Item
Agree (Agree)
CL Item
Strongly Agree (Strongly Agree)
Item Group
Ccrr Module For Calgb: Adherence Questionnaire Form (follow-up)
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