ID

10553

Beschrijving

Acute Leukemia Disease Assessment Form NCT00049517 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=A727ECDC-BAED-2F88-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727ECDC-BAED-2F88-E034-0003BA0B1A09

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 28-05-15 28-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

3 juni 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Acute Leukemia Disease Assessment Form NCT00049517

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Acute Leukemia Disease Assessment Form
    1. No Instruction available.
ECOG clinical trial administrative data
Beschrijving

ECOG clinical trial administrative data

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Cycle Number
Beschrijving

CycleNumber

Datatype

text

Patient?s Name
Beschrijving

Patient'sName

Datatype

text

ECOG Protocol No.
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Protocol No.
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Patient ID
Beschrijving

ECOGPatientID

Datatype

text

ECOG Patient ID
Beschrijving

ECOGPatientID

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient ID
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Acute Leukemia Disease assessment
Beschrijving

Acute Leukemia Disease assessment

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

AmendedDataInd

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Date of bone marrow biopsy
Beschrijving

BoneMarrowBiopsyDate

Datatype

date

Marrow blasts (%)
Beschrijving

BoneMarrow,Blasts,CellPercentage

Datatype

double

Marrow cellularity (%)
Beschrijving

BoneMarrow,CellularityPercentage

Datatype

double

Are all cell lines maturing?
Beschrijving

Areallcelllinesmaturing?

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Are auer rods present?
Beschrijving

BoneMarrowAuerrods

Datatype

text

Is there extramedullary disease
Beschrijving

Isthereextramedullarydisease

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
yes, specify sites (extramedullary disease)
Beschrijving

ExtramedullaryDisease,OtherSite

Datatype

text

Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
Beschrijving

CompleteResponseInd,Hematologic

Datatype

text

Date of complete response
Beschrijving

CRFirstObservedDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C25755
UMLS 2011AA ObjectClass
C0871261
NCI Thesaurus Property
C15722
UMLS 2011AA Property
C0700325
Comments
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

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

InvestigatorSignatureDate

Datatype

date

Ccrr Module For Acute Leukemia Disease Assessment Form
Beschrijving

Ccrr Module For Acute Leukemia Disease Assessment Form

specify sites of extramedullary disease
Beschrijving

specifysitesofextramedullarydisease

Datatype

text

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Acute Leukemia Disease Assessment Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
ECOG clinical trial administrative data
RegistrationStep
Item
Registration Step
text
CycleNumber
Item
Cycle Number
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Acute Leukemia Disease assessment
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
BoneMarrowBiopsyDate
Item
Date of bone marrow biopsy
date
BoneMarrow,Blasts,CellPercentage
Item
Marrow blasts (%)
double
BoneMarrow,CellularityPercentage
Item
Marrow cellularity (%)
double
Item
Are all cell lines maturing?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.2
Code List
Are all cell lines maturing?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Are auer rods present?
text
CL.3
Code List
Are auer rods present?
CL Item
Auer Rods Absent From Bone Marrow (absent)
CL Item
Auer Rods Present In Bone Marrow (present)
Item
Is there extramedullary disease
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
Is there extramedullary disease
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ExtramedullaryDisease,OtherSite
Item
yes, specify sites (extramedullary disease)
text
Item
Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
text
CL.5
Code List
Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
CL Item
Null (no)
CL Item
Null (yes)
CL Item
Null (unknown)
CRFirstObservedDate
Item
Date of complete response
date
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C15722 (NCI Thesaurus Property)
C0700325 (UMLS 2011AA Property)
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 Acute Leukemia Disease Assessment Form
specifysitesofextramedullarydisease
Item
specify sites of extramedullary disease
text
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial