CALGB: CHANGES IN FUNCTION FORM NCT00024102

CALGB: CHANGES IN FUNCTION FORM NCT00024102 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=A50D6975-F5AD-3262-E034-080020C9C0E0 NCT00024102

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.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (M)
date
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item
Amended data?
text
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Assessment data
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1.)
float
Item Group
Patient status assessment
Item
Has your physical condition gotten (2.)
text
Code List
Has your physical condition gotten (2.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your emotional state gotten (3.)
text
Code List
Has your emotional state gotten (3.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your ability to enjoy your social life gotten (4.)
text
Code List
Has your ability to enjoy your social life gotten (4.)
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item
Has your overall quality of life gotten
text
Code List
Has your overall quality of life gotten
CL Item
Very Much Worse (very much worse)
CL Item
Moderately Worse (moderately worse)
CL Item
A Little Worse (a little worse)
CL Item
About The Same (about the same)
CL Item
A Little Better (a little better)
CL Item
Moderately Better (moderately better)
CL Item
Very Much Better (very much better)
Item Group
Ccrr Module For Calgb: Changes In Function Form