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Información:
Error:
ID
6217
Descripción
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
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Palabras clave
Versiones (2)
- 18/12/14 18/12/14 - Martin Dugas
- 24/3/15 24/3/15 - Martin Dugas
Subido en
18 de diciembre de 2014
DOI
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Licencia
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
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
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (6.)
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
Item
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
text
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
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
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 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 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)
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
I will be just as healthy even if I were not taking my cancer medication. (7.)
text
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 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 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
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
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 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 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 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)