ID
6217
Beschrijving
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
Trefwoorden
Versies (2)
- 18-12-14 18-12-14 - Martin Dugas
- 24-03-15 24-03-15 - Martin Dugas
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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: 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.
Beschrijving
Unnamed2
Beschrijving
Patient'sName
Datatype
text
Beschrijving
ParticipatingGroup
Datatype
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschrijving
PatientHospitalNumber
Datatype
text
Beschrijving
ParticipatingGroupProtocolNo.
Datatype
text
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MainMemberInstitution/Adjunct
Datatype
text
Beschrijving
ParticipatingGroupPatientNo.
Datatype
text
Beschrijving
Unnamed3
Beschrijving
Unnamed4
Beschrijving
ThebenefitsofmycancertreatmentoutweighthedifficultiesIhaveinfollowingit.
Datatype
text
Beschrijving
IbelievethattakingmycancermedicationistoomuchtroubleforwhatIwillgetoutofit.
Datatype
text
Beschrijving
Becausetheschedulefortakingmycancermedicationistoodifficult,itisnotbeworthfollowingit.
Datatype
text
Beschrijving
Takingmycancermedicationisbetterformethannottakingit.
Datatype
text
Beschrijving
Takingmycancermedicationishelpingmetobehealthy.
Datatype
text
Beschrijving
Unnamed5
Beschrijving
Unnamed6
Beschrijving
IwillbejustashealthyevenifIwerenottakingmycancermedication.
Datatype
text
Beschrijving
Ibelievethatmycancertreatmentishelpingtocuremeofcancer.
Datatype
text
Beschrijving
Itishardtobelievethatmycancertreatmentishelpingme.
Datatype
text
Beschrijving
Lotsofthingsaregettinginthewayoffollowingtheschedulefortakingmycancermedication.
Datatype
text
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Ineedmoreassistanceinordertofollowtheschedulefortakingmycancermedication.
Datatype
text
Beschrijving
IamgettingthehelpIneedtofollowmycancermedicationschedule.
Datatype
text
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Iamabletodealwithanyproblemsintakingmycancermedication.
Datatype
text
Beschrijving
Thesideeffectsofmycancermedicationdisruptmynormalactivities.
Datatype
text
Beschrijving
Ccrr Module For Calgb: Adherence Questionnaire Form (follow-up)
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)