ID

10583

Description

E1900 Non-Protocol Therapy 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=A7293E99-DB96-2FBE-E034-0003BA0B1A09

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7293E99-DB96-2FBE-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

3 juin 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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E1900 Non-Protocol Therapy Form NCT00049517

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: E1900 Non-Protocol Therapy 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

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
Non-protocol therapy
Description

Non-protocol therapy

Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
Description

Non-ProtocolTherapyDate,First

Type de données

date

Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
Description

Type(s)offirstnon-protocoltherapy

Type de données

text

Name of other non-protocol therapy:
Description

OtherNon-ProtocolTherapyName

Type de données

text

Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
Description

Wasthenon-protocoltherapygivenforthediseaseofthisprotocol?

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
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 Non-protocol Therapy Form
Description

Ccrr Module For E1900 Non-protocol Therapy Form

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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: E1900 Non-Protocol Therapy 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
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
Non-protocol therapy
Non-ProtocolTherapyDate,First
Item
Date of FIRST non-protocol therapy (if given prior to progression/relapse from protocol therapy:)
date
Item
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
text
CL.2
Code List
Type(s) of first non-protocol therapy (which includes any cancer therapy that is not part of the planned regimen.)
CL Item
Non-protocol Chemotherapy (Non-protocol Chemotherapy)
CL Item
Non-protocol Hormonal Therapy (Non-protocol Hormonal Therapy)
CL Item
Non-protocol Immunotherapy/biological Response Modifiers (Non-protocol Immunotherapy/Biological Response Modifiers)
CL Item
Non-protocol High Dose Chemotherapy/stem Cell Transplant (autologous Or Allogeneic) (Non-protocol High Dose Chemotherapy/Stem Cell Transplant (Autologous or Allogeneic))
CL Item
Non-protocol Surgery (Non-protocol Surgery)
CL Item
Non-protocol Radiation Therapy (Non-protocol Radiation Therapy)
CL Item
Other Non-protocol Therapy (Other Non-protocol Therapy)
OtherNon-ProtocolTherapyName
Item
Name of other non-protocol therapy:
text
Item
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.3
Code List
Was the non-protocol therapy given for the disease of this protocol? (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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 Non-protocol Therapy Form
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