ID

8875

Description

CALGB: 80203 BACKGROUND INFORMATION FORM Fluorouracil and Leucovorin Plus Either Irinotecan or Oxaliplatin With or Without Cetuximab in Treating Patients With Previously Untreated Metastatic Adenocarcinoma of the Colon or Rectum Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFD5AAD1-D500-39A2-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFD5AAD1-D500-39A2-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00077233 Demographic - CALGB: 80203 BACKGROUND INFORMATION FORM - 2171121v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB: 80203 BACKGROUND INFORMATION FORM
    1. No Instruction available.
Ccrr Module For Calgb: 80203 Background Information Form
Description

Ccrr Module For Calgb: 80203 Background Information Form

Patient Hospital No.
Description

Medical Record Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
Institution/Affiliate
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Today's date
Description

Today'sDate

Data type

text

What is the highest grade you finished in school? (Mark one with an X)
Description

Whatisthehighestgradeyoufinishedinschool?

Data type

text

What is your marital status? (Mark one with an X)
Description

Whatisyourmaritalstatus?

Data type

text

With whom do you live? (Mark all that apply with an X)
Description

Withwhomdoyoulive?

Data type

text

What is your current employment status? (Mark all that apply with an X)
Description

Whatisyourcurrentemploymentstatus?

Data type

text

Patient Initials
Description

PatientInitials

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Other, specify
Description

Other,specify

Data type

text

Other relative, specify
Description

Otherrelative,specify

Data type

text

Other, specify
Description

Other,specify

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB: 80203 BACKGROUND INFORMATION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb: 80203 Background Information Form
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
Today'sDate
Item
Today's date
text
Item
What is the highest grade you finished in school? (Mark one with an X)
text
CL.1
Code List
What is the highest grade you finished in school? (Mark one with an X)
CL Item
1-8 Grades (1-8 grades)
CL Item
9-11 Grades (9-11 grades)
CL Item
High School Graduate (High School graduate)
C67136 (NCI Thesaurus)
C0870649 (UMLS 2011AA)
CL Item
Some College (Some college)
CL Item
Junior College Degree (Junior college degree)
CL Item
College Degree (b.a./b.s.) (College degree (B.A./B.S.))
CL Item
Some Post-college Work (Some post-college work)
CL Item
Advanced Degree (Advanced degree)
Item
What is your marital status? (Mark one with an X)
text
CL.2
Code List
What is your marital status? (Mark one with an X)
CL Item
Single, Never Married (Single, never married)
CL Item
Married (Married)
C0555047 (NCI Metathesaurus)
CL Item
Separated (Separated)
C51777 (NCI Thesaurus)
C0086972 (UMLS 2011AA)
CL Item
Divorced (Divorced)
C0086170 (NCI Metathesaurus)
CL Item
Widowed (Widowed)
C51775 (NCI Thesaurus)
C0206275 (UMLS 2011AA)
Item
With whom do you live? (Mark all that apply with an X)
text
CL.3
Code List
With whom do you live? (Mark all that apply with an X)
CL Item
Spouse/partner (Spouse/Partner)
CL Item
Children Aged 18 Years Or Younger (Children aged 18 years or younger)
CL Item
Children Aged 19 Years Or Older (Children aged 19 years or older)
CL Item
Parent(s)/parent(s)-in-law (Parent(s)/Parent(s)-In-Law)
CL Item
Other Relative, Specify (Other relative, specify)
CL Item
Live Alone (Live alone)
CL Item
Other, Specify (Other, specify)
CL Item
Other Relative, Specify (Other relative, specify)
Item
What is your current employment status? (Mark all that apply with an X)
text
CL.4
Code List
What is your current employment status? (Mark all that apply with an X)
CL Item
Employed 32 Hours Or More Per Week (Employed 32 hours or more per week)
CL Item
Employed less than 32 hours per week (Employed less than 32 hours per week)
CL Item
Full-time Student (Full-time student)
CL Item
Part-time Student (Part-time student)
CL Item
Homemaker (Homemaker)
C0555052 (NCI Metathesaurus)
CL Item
On Medical Leave (On medical leave)
CL Item
Disabled (Disabled)
C63367 (NCI Thesaurus)
C1880351 (UMLS 2011AA)
CL Item
Unemployed (Unemployed)
C0425086 (NCI Metathesaurus)
CL Item
Retired (Retired)
CL Item
Other, Specify (Other, specify)
PatientInitials
Item
Patient Initials
text
ParticipatingGroup
Item
Participating Group
text
Other,specify
Item
Other, specify
text
Otherrelative,specify
Item
Other relative, specify
text
Other,specify
Item
Other, specify
text
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