ID
790
Description
CALGB: 49907 ADJUVANT TREATMENT SUMMARY FORM; All Patients 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=A50D76F4-2138-330D-E034-080020C9C0E0
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 4/22/15 4/22/15 - 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 Treatment - CALGB: 49907 ADJUVANT TREATMENT SUMMARY FORM; All Patients - 2042891v3.0
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.
Description
Unnamed2
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
MainMemberInstitution/Adjunct
Data type
text
Description
ParticipatingGroupPatientNo.
Data type
text
Description
Treatment Cycle Information
Description
TotalDoseofDrugsforCycle1
Data type
double
Description
AgentName
Data type
text
Description
ReasonTreatmentEnded
Data type
text
Description
Other,specify(reasontreatmentended)
Data type
text
Description
Unnamed3
Description
Patient'sName
Data type
text
Description
CALGBForm
Data type
text
Description
CALGBStudyNo
Data type
text
Description
CALGBPatientID
Data type
text
Description
FirstDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain
- C25509
- UMLS 2011AA ValueDomain
- C1279901
Description
Unnamed4
Description
Werethereanydosemodificationsoradditions/omissionstoprotocoltreatment?
Data type
text
Description
Wereanyoptionalprotocoltherapiesgiven?
Data type
text
Description
optionalprotocoltherapyname(s)
Data type
text
Description
Wasanyconcurrentnon-protocoltherapygivenduringprotocoltreatment?
Data type
text
Description
indicatebelow(concurrentnon-protocoltherapygivenduringprotocoltreatment)
Data type
text
Description
Comments
Description
Unnamed5
Description
Ccrr Module For Calgb: 49907 Adjuvant Treatment Summary Form; All Patients
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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.
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0010583 (UMLS 2011AA)
C0025677 (UMLS 2011AA)
C0016360 (UMLS 2011AA)
C0671970 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain)
C1279901 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)