ID

10325

Description

E1900 Toxicity Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294BEF-41E2-2FCE-E034-0003BA0B1A09

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294BEF-41E2-2FCE-E034-0003BA0B1A09

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
Téléchargé le

28 mai 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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    E1900 Toxicity Form

    Anglais

    No Instruction available.

    1 Formulaires  
    1. StudyEvent: E1900 Toxicity Form
      1. No Instruction available.
    ECOG clinical trial administrative data
    Description

    ECOG clinical trial administrative data

    ECOG Protocol No.
    Description

    ECOGProtocolNo.

    Type de données

    text

    ECOG Patient ID
    Description

    ECOGPatientID

    Type de données

    text

    Registration Step
    Description

    RegistrationStep

    Type de données

    text

    Adverse Event Reporting From Date (M D Y)
    Description

    CTCAdverseEventReportBeginDate

    Type de données

    date

    Adverse Event Reporting To Date (M D Y)
    Description

    CTCAdverseEventReportEndDate

    Type de données

    date

    Reporting Period
    Description

    TreatmentPhase

    Type de données

    text

    Patient?s Name
    Description

    Patient'sName

    Type de données

    text

    Participating Group Protocol No.
    Description

    ParticipatingGroupProtocolNo.

    Type de données

    text

    Participating Group Patient ID
    Description

    ParticipatingGroupPatientID

    Type de données

    text

    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Type de données

    text

    Are data amended? (If yes, please circle amended items in red)
    Description

    AmendedDataInd

    Type de données

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Adverse event assessment
    Description

    Adverse event assessment

    CTC Adverse Event Term
    Description

    CTCAdverseEventTerm

    Type de données

    text

    CTC Adverse Event Grade
    Description

    CTCAdverseEventGrade

    Type de données

    text

    CTC Adverse Event Attribution Code
    Description

    CTCAdverseEventAttributionCode

    Type de données

    text

    Other CTC Adverse Event Term(s) not listed (Use CTC terminology)
    Description

    CTCAdverseEventTerm,Other

    Type de données

    text

    Comments
    Description

    Comments

    Comments
    Description

    Comments

    Type de données

    text

    Investigator Signature
    Description

    InvestigatorSignature

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    Date
    Description

    InvestigatorSignatureDate

    Type de données

    date

    Ccrr Module For E1900 Toxicity Form
    Description

    Ccrr Module For E1900 Toxicity Form

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    Similar models

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    1 Formulaires
    1. StudyEvent: E1900 Toxicity Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    ECOG clinical trial administrative data
    ECOGProtocolNo.
    Item
    ECOG Protocol No.
    text
    ECOGPatientID
    Item
    ECOG Patient ID
    text
    RegistrationStep
    Item
    Registration Step
    text
    CTCAdverseEventReportBeginDate
    Item
    Adverse Event Reporting From Date (M D Y)
    date
    CTCAdverseEventReportEndDate
    Item
    Adverse Event Reporting To Date (M D Y)
    date
    Item
    Reporting Period
    text
    CL.1
    Code List
    Reporting Period
    CL Item
    Current Phase Of Leukemia Treatment For Patient Is Induction (induction)
    CL Item
    Current Phase Of Leukemia Treatment For Patient Is Consolidation (consolidation)
    CL Item
    post transplant (post transplant)
    Patient'sName
    Item
    Patient?s Name
    text
    ParticipatingGroupProtocolNo.
    Item
    Participating Group Protocol No.
    text
    ParticipatingGroupPatientID
    Item
    Participating Group Patient ID
    text
    MainMemberInstitution/Affiliate
    Item
    Institution/Affiliate
    text
    AmendedDataInd
    Item
    Are data amended? (If yes, please circle amended items in red)
    boolean
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    Item Group
    Adverse event assessment
    CTCAdverseEventTerm
    Item
    CTC Adverse Event Term
    text
    CTCAdverseEventGrade
    Item
    CTC Adverse Event Grade
    text
    Item
    CTC Adverse Event Attribution Code
    text
    CL.3
    Code List
    CTC Adverse Event Attribution Code
    CL Item
    Unrelated (unrelated)
    C25328 (NCI Thesaurus)
    C0445356 (UMLS 2011AA)
    CL Item
    Unlikely (unlikely)
    CL Item
    Possibly (possible)
    CL Item
    Probably (probable)
    CL Item
    Definitely (definite)
    CTCAdverseEventTerm,Other
    Item
    Other CTC Adverse Event Term(s) not listed (Use CTC terminology)
    text
    Item Group
    Comments
    Comments
    Item
    Comments
    text
    InvestigatorSignature
    Item
    Investigator Signature
    text
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    InvestigatorSignatureDate
    Item
    Date
    date
    Item Group
    Ccrr Module For E1900 Toxicity Form
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