ID

698

Description

CALGB: 49907 CYCLOPHOSPHAMIDE MEDICATION CALENDAR 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=A50CFEAE-D13B-3952-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CFEAE-D13B-3952-E034-080020C9C0E0

Keywords

  1. 8/26/12 8/26/12 -
  2. 3/18/15 3/18/15 - Martin Dugas
Uploaded on

August 26, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00024102 Flow Sheet - CALGB: 49907 CYCLOPHOSPHAMIDE MEDICATION CALENDAR - 2044970v3.0

PATIENT INSTRUCTIONS: Use this calendar as a reminder to take your medication. Be sure to mark an "x" in each box for each day that you take your pills, record the time you took them, and circle AM or PM.

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

Amended data?
Description

Amendeddata?

Data type

text

Unnamed2
Description

Unnamed2

Patient's Name
Description

Patient'sName

Data type

text

Cycle number
Description

CycleNumber

Data type

text

Day 1 of cycle (M)
Description

Day1ofcycle

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed3
Description

Unnamed3

DAY OF WEEK
Description

DAYOFWEEK

Data type

text

Day of cycle
Description

Dayofcycle

Data type

text

TOOK PILLS
Description

TOOKPILLS

Data type

text

Took pills time
Description

Tookpillstime

Data type

text

AM or PM (CRA use only)
Description

AMorPM

Data type

text

Unnamed4
Description

Unnamed4

Unnamed5
Description

Unnamed5

TOTAL NUMBER OF DAYS PILLS TAKEN THIS CYCLE
Description

TOTALNUMBEROFDAYSPILLSTAKENTHISCYCLE

Data type

double

Unnamed6
Description

Unnamed6

Completed By (Print or Type Name)
Description

CompletedBy

Data type

text

Date Completed (M)
Description

DateCompleted

Data type

date

Ccrr Module For Calgb: 49907 Cyclophosphamide Medication Calendar
Description

Ccrr Module For Calgb: 49907 Cyclophosphamide Medication Calendar

Similar models

PATIENT INSTRUCTIONS: Use this calendar as a reminder to take your medication. Be sure to mark an "x" in each box for each day that you take your pills, record the time you took them, and circle AM or PM.

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
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
CycleNumber
Item
Cycle number
text
Day1ofcycle
Item
Day 1 of cycle (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Unnamed3
DAYOFWEEK
Item
DAY OF WEEK
text
Item
Day of cycle
text
Code List
Day of cycle
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
CL Item
11 (11)
CL Item
12 (12)
CL Item
13 (13)
CL Item
14 (14)
TOOKPILLS
Item
TOOK PILLS
text
Tookpillstime
Item
Took pills time
text
Item
AM or PM (CRA use only)
text
Code List
AM or PM (CRA use only)
CL Item
Am (AM)
CL Item
Pm (PM)
Item Group
Unnamed4
Item Group
Unnamed5
TOTALNUMBEROFDAYSPILLSTAKENTHISCYCLE
Item
TOTAL NUMBER OF DAYS PILLS TAKEN THIS CYCLE
double
Item Group
Unnamed6
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date
Item Group
Ccrr Module For Calgb: 49907 Cyclophosphamide Medication Calendar

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