PACCT-1 TAILORx Assessment Compliance Form Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder:

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

January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00310180 Quality of Life - PACCT-1 TAILORx Assessment Compliance Form - 3071476v1.0

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Report Period
Are data amended
E2906 Qol Assessment Not Completed
Section Ii - E1a05 Qol Assessment Not Completed
Were all the quality of life forms completed for this timepoint
Section Ii - Assessments Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Section Iii Assessment Completed
Was Assessment self-administered?
How Was The Patient Assisted
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
What Was The Reason For Assistance
Did the patient have a language difficulty (questions needed to tbe translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Patient Bowel Function/uniscale Questionnaire: Who Assisted Or Completed Assessment?

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