ID

10582

Descripción

E1900 Toxicity 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=A7294BEF-41E2-2FCE-E034-0003BA0B1A09

Link

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

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
Subido en

3 de junio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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E1900 Toxicity Form NCT00049517

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: E1900 Toxicity Form
    1. No Instruction available.
ECOG clinical trial administrative data
Descripción

ECOG clinical trial administrative data

ECOG Protocol No.
Descripción

ECOGProtocolNo.

Tipo de datos

text

ECOG Patient ID
Descripción

ECOGPatientID

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Adverse Event Reporting From Date (M D Y)
Descripción

CTCAdverseEventReportBeginDate

Tipo de datos

date

Adverse Event Reporting To Date (M D Y)
Descripción

CTCAdverseEventReportEndDate

Tipo de datos

date

Reporting Period
Descripción

TreatmentPhase

Tipo de datos

text

Patient?s Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Participating Group Patient ID
Descripción

ParticipatingGroupPatientID

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

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

AmendedDataInd

Tipo de datos

boolean

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

Adverse event assessment

CTC Adverse Event Term
Descripción

CTCAdverseEventTerm

Tipo de datos

text

CTC Adverse Event Grade
Descripción

CTCAdverseEventGrade

Tipo de datos

text

CTC Adverse Event Attribution Code
Descripción

CTCAdverseEventAttributionCode

Tipo de datos

text

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

CTCAdverseEventTerm,Other

Tipo de datos

text

Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

Investigator Signature
Descripción

InvestigatorSignature

Tipo de datos

text

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

InvestigatorSignatureDate

Tipo de datos

date

Ccrr Module For E1900 Toxicity Form
Descripción

Ccrr Module For E1900 Toxicity Form

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: E1900 Toxicity Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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