ID

10578

Description

E1900 Second Primary 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=A72941B2-95F8-2FC4-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A72941B2-95F8-2FC4-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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E1900 Second Primary Form NCT00049517

English

No Instruction available.

1 forms  
  1. StudyEvent: E1900 Second Primary Form
    1. No Instruction available.
ECOG clinical trial administrative data
Description

ECOG clinical trial administrative data

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient?s Name
Description

Patient'sName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

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

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Diagnosis Second Primary Cancer
Description

Diagnosis Second Primary Cancer

Date of Diagnosis of Second Primary Cancer
Description

DateofDiagnosisofSecondPrimaryCancer

Data type

text

Site of Second Primary Cancer
Description

SecondPrimaryMalignantNeoplasmAnatomicSiteText

Data type

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25666
UMLS 2011AA ObjectClass-3
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C25421
UMLS 2011AA Property-2
C0002808
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Include information on histologic subtype(s).
Description

Includeinformationonhistologicsubtype(s).

Data type

text

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
Description

BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols

Data type

text

Briefly describe treatment planned or given for the diagnosis of this second primary:
Description

Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Investigator Signature
Description

InvestigatorSignature

Data type

text

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

InvestigatorSignatureDate

Data type

date

Ccrr Module For E1900 Second Primary Form
Description

Ccrr Module For E1900 Second Primary Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E1900 Second Primary Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOG clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
RegistrationStep
Item
Registration Step
text
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
Diagnosis Second Primary Cancer
DateofDiagnosisofSecondPrimaryCancer
Item
Date of Diagnosis of Second Primary Cancer
text
SecondPrimaryMalignantNeoplasmAnatomicSiteText
Item
Site of Second Primary Cancer
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C0205436 (UMLS 2011AA ObjectClass-3)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property-2)
C0002808 (UMLS 2011AA Property-2)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s).
text
BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols
text
Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:
Item
Briefly describe treatment planned or given for the diagnosis of this second primary:
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 Second Primary Form
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