E2108 Assessment Compliance Form Early Surgery or Standard Palliative Therapy in Treating Patients With Stage IV Breast Cancer Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01242800 Quality of Life - E2108 Assessment Compliance Form - 3128759v1.0

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 (since start of treatment Choose one)
Section I
Section Ii - E1a05 Qol Assessment Not Completed
Was the Assessment Form completed? (E2108 FACT-B + 10)
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 be 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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