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ID
2048
Description
S0100 PATHOLOGY SUBMISSION FORM - LEUKEMIA ADDENDUM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB41C46-31DA-419A-E034-0003BA12F5E7
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Keywords
Versions (3)
- 9/19/12 9/19/12 -
- 8/3/17 8/3/17 - Martin Dugas
- 8/3/17 8/3/17 - Martin Dugas
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September 19, 2012
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Creative Commons BY-NC 3.0
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Leukemia null Pathology - S0100 PATHOLOGY SUBMISSION FORM - LEUKEMIA ADDENDUM - 2070739v3.0
Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Notes section at the bottom of the form. Place an X in appropriate boxes. Circle AMENDED items in red.
- StudyEvent: S0100 PATHOLOGY SUBMISSION FORM - LEUKEMIA ADDENDUM
Similar models
Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Notes section at the bottom of the form. Place an X in appropriate boxes. Circle AMENDED items in red.
- StudyEvent: S0100 PATHOLOGY SUBMISSION FORM - LEUKEMIA ADDENDUM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
SWOGPatientID
Item
SWOG Patient No.
text
TreatmentStep
Item
Protocol Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Member
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
RegistrationDate
Item
Date Registered (month, day, year)
text
SpecimenCollectionDate
Item
Date sample obtained
date
SpecimenCollectionTime
Item
Time sample obtained (24 hour)
date
Item
Disease (check only one disease; check one subcategory for that disease {if appropriate})
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Code List
Disease (check only one disease; check one subcategory for that disease {if appropriate})
CL Item
Disease Classified As All, Not Otherwise Specified (nos); (Acute lymphocytic leukemia (ALL))
CL Item
Disease Classified As Acute Lympoblastic Leukemia (fab L1) (Acute lymphocytic leukemia L1)
CL Item
Disease Classified As Acute Lymphoblastic Leukemia (fab L2) (Acute lymphocytic leukemia L2)
CL Item
Disease Classified As Acute Lymphoblastic Leukemia (fab L3) (Acute lymphocytic leukemia L3)
CL Item
Disease Classified As All, Not Otherwise Specified (nos); (ALL, Other)
CL Item
Disease Classified As Aml, Not Otherwise Specified (nos) (Acute myelogenous leukemia (AML))
CL Item
Disease Classified As Acute Myeloid Leukemia W/o Maturation (fab M1) (Acute myelogenous leukemia M1)
CL Item
Disease Classified As Acute Myeloid Leukemia W/ Maturation (fab M2) (Acute myelogenous leukemia M2)
CL Item
Disease Classified As Acute Promyelocytic Leukemia (fab M3) (Acute myelogenous leukemia M3)
CL Item
Acute myelogenous leukemia M3m (Acute myelogenous leukemia M3m)
CL Item
Disease Classified As Acute Myelomonocytic Leukemia (fab M4) (Acute myelogenous leukemia M4)
CL Item
Acute myelogenous leukemia M4eos (Acute myelogenous leukemia M4eos)
CL Item
Disease Classified As Acute Monocytic Leukemia (fab M5) (Acute myelogenous leukemia M5)
CL Item
Acute myelogenous leukemia M5a (Acute myelogenous leukemia M5a)
CL Item
Acute myelogenous leukemia M5b (Acute myelogenous leukemia M5b)
CL Item
Acute myelogenous leukemia M6 (Acute myelogenous leukemia M6)
CL Item
Disease Classified As Acute Megakaryoblastic Leukemia (fab M7) (Acute myelogenous leukemia M7)
CL Item
Acute myelogenous leukemia M0 (Acute myelogenous leukemia M0)
CL Item
AML, Other (AML, Other)
CL Item
Biphenotypic (Biphenotypic)
CL Item
Disease Classified As Chronic Lymphocytic Leukemia (cll) (Chronic lymphocytic leukemia (CLL))
CL Item
Disease Classified As Cml, Not Otherwise Specified (nos); (Chronic myelogenous leukemia (CML))
CL Item
Disease Classified As Chronic Myelogenous Leukemia (cml), Chronic Phase (Chronic myelogenous leukemia Chronic phase)
CL Item
Disease Classified As Chronic Myelogenous Leukemia, (cml), Blast Crisis (Chronic myelogenous leukemia Blast phase/crisis)
CL Item
Chronic Myelogenous Leukemia (cml), Accelerating Phase, Lymphoid (Chronic myelogenous leukemia Accelerating phase)
CL Item
Disease Classified As Cml, Not Otherwise Specified (nos); (CML, Other specify)
CL Item
Disease Classified As Hairy Cell Leukemia (Hairy cell leukemia)
CL Item
Disease Classified As Myelodysplastic Syndrome (mds) Nos (Myelodysplastic Syndrome (MDS))
CL Item
Disease Classified As Refractory Anemia (ra) (Myelodysplastic Syndrome Refractory anemia (RA))
CL Item
Disease Classified As Refractory Anemia W/ Ring Sideroblasts (rars) (Myelodysplastic Syndrome Refractory anemia with ring sideroblasts (RARS))
CL Item
Disease Classified As Refractory Anemia W/excess Blasts (raeb) (Myelodysplastic Syndrome Refractory anemia with excess blasts (RAEB))
CL Item
Disease Classified As Refractory Anemia W/ Excess Blasts In Transformation (raeb-t) (Myelodysplastic Syndrome Refractory anemia with excess blasts in transformation (RAEB-T))
CL Item
Disease Classified As Chronic Myelomonocytic Leukemia (cmml) (Myelodysplastic Syndrome Chronic myelomonocytic leukemia (CMMoL or CMML))
CL Item
Disease Classified As Myelodysplastic Syndrome (mds) Nos (Myelodysplastic syndrome, other specify)
CL Item
Disease Classified As Specified Other Leukemia (Other disease)
LeukemiaClassification,Other
Item
Myelodysplastic syndrome, other specify
text
LeukemiaClassification,Other
Item
Myelodysplastic syndrome, other specify
text
LeukemiaClassification,Other
Item
Myelodysplastic syndrome, other specify
text
LeukemiaClassification,Other
Item
Myelodysplastic syndrome, other specify
text
LeukemiaClassification,Other
Item
Myelodysplastic syndrome, other specify
text
Otherdisease,specify
Item
Other disease, specify
text
CL Item
Sudan Black (Sudan black)
CL Item
Myeloperoxidase Chloroacetate (Myeloperoxidase chloroacetate)
CL Item
Specific Esterase (Specific esterase)
CL Item
Non Specific Esterase (Non specific esterase)
CL Item
Other, Specify Stain (Other, specify stain)
Other,specifystain
Item
Other, specify stain
text
Sudanblack,Result
Item
Sudan black, Result
text
Myeloperoxidasechloroacetate,Result
Item
Myeloperoxidase chloroacetate, Result
text
Specificesterase,Result
Item
Specific esterase, Result
text
Nonspecificesterase,Result
Item
Non specific esterase, Result
text
Other,specifystain,Result
Item
Other, specify stain, Result
text
CL Item
Naphtyl-asd-acetate (naphtyl-ASD-acetate)
CL Item
Alpha-naphthyl Butyrate (alpha-naphthyl butyrate)
C0051445 (NCI Metathesaurus)
CL Item
Alpha-naphthyl Acetate (alpha-naphthyl acetate)
C0051444 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
other,specify(non-specificesterase)
Item
other, specify (non-specific esterase)
text
Comments
Item
Notes
text