ID
802
Beschreibung
CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD FORM 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=A50CE624-6F5F-37E3-E034-080020C9C0E0
Link
Stichworte
Versionen (2)
- 26.08.12 26.08.12 -
- 20.05.15 20.05.15 - Martin Dugas
Hochgeladen am
26. August 2012
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102 Transmittal - CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD FORM - 2044684v3.0
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 Statistical Center, Data Operations. 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.
Beschreibung
Unnamed2
Beschreibung
Patient'sName
Datentyp
text
Beschreibung
ParticipatingGroup
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
PatientHospitalNumber
Datentyp
text
Beschreibung
ParticipatingGroupProtocolNo.
Datentyp
text
Beschreibung
MainMemberInstitution/Adjunct
Datentyp
text
Beschreibung
ParticipatingGroupPatientNo.
Datentyp
text
Beschreibung
Unnamed3
Beschreibung
Dailycapecitabinedose
Datentyp
double
Beschreibung
Numberof500mgtabletsprescribedtobetakeneachday
Datentyp
double
Beschreibung
Numberof500mgtabletsissued
Datentyp
double
Beschreibung
Dateandtimetheelectronicdevicewasplacedonthevial
Datentyp
text
Beschreibung
Nameofthepersonwhofilledthevial
Datentyp
text
Beschreibung
Unnamed4
Beschreibung
DateandTimepillcountwasdone
Datentyp
text
Beschreibung
Howmany500mgtabletsreturned
Datentyp
double
Beschreibung
Dateandtimetheelectronicdevicewasremovedfromthevial
Datentyp
text
Beschreibung
Nameofthepersonwhoperformedthereturnpillcount
Datentyp
text
Beschreibung
CompletedBy
Datentyp
text
Beschreibung
DateCompleted
Datentyp
date
Beschreibung
Ccrr Module For Calgb: 49907 Capecitabine Drug Supply Record Form
Ähnliche Modelle
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 Statistical Center, Data Operations. 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)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)