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ID

10888

Descrição

NCT00093470 ECOG Acute Leukemia Disease Assessment Form - Form 1651 Tipifarnib in Treating Patients With Acute Myeloid Leukemia in Remission Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DBD30C56-F431-6847-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DBD30C56-F431-6847-E034-0003BA12F5E7

Palavras-chave

  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 12/06/2015 12/06/2015 -
Transferido a

12 de junho de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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    NCT00093470 ECOG Acute Leukemia Disease Assessment Form - Form 1651

    No Instruction available.

    1. StudyEvent: ECOG Acute Leukemia Disease Assessment Form - Form 1651
      1. No Instruction available.
    Header
    Descrição

    Header

    ECOG Protocol Number
    Descrição

    Protocol Number ECOG

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    ECOG Patient ID
    Descrição

    Patient ID ECOG

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1512162
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25491
    DCI Name (Place ID Label Here)
    Descrição

    Generic drug form

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C3242750
    NCI Thesaurus Property
    C19464
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus ObjectClass-2
    C25452
    Patient Initials (Last, First)
    Descrição

    Patient Initials

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Participating Group Protocol Number
    Descrição

    Study Number Participating Group

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Patient ID
    Descrição

    Trial subject ID Participating Group

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Institution/Affiliate
    Descrição

    Institution Name

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Registration Step
    Descrição

    Registration Number

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Report Period
    Descrição

    ReportingPeriod

    Tipo de dados

    text

    Are data amended
    Descrição

    Data amended

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    ECOG Acute Leukemia Assessment
    Descrição

    ECOG Acute Leukemia Assessment

    Date of Bone Marrow Biopsy (or Aspirate Confirming relapse)
    Descrição

    BoneMarrowBiopsyDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C15189
    UMLS 2011AA Property
    C0005558
    NCI Thesaurus ObjectClass
    C12431
    UMLS 2011AA ObjectClass
    C0005953
    Marrow Blasts (%)
    Descrição

    Blasts, Bone Marrow

    Tipo de dados

    float

    Unidades de medida
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C1982687
    NCI Thesaurus Property
    C12431
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus Property-3
    C12918
    NCI Thesaurus ValueDomain
    C25613
    NCI Thesaurus ValueDomain-2
    C25712
    %
    Marrow Cellularity (%)
    Descrição

    Bone Marrow Cellularity

    Tipo de dados

    float

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C1561532
    NCI Thesaurus Property
    C12431
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus Property-3
    C37923
    NCI Thesaurus ValueDomain
    C25613
    NCI Thesaurus ValueDomain-2
    C25712
    Date Hematology (Blood) Sample Obtained
    Descrição

    HematologyLabCollectedDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain-2
    C25452
    Peripheral Leukemic blasts
    Descrição

    PeripheralBloodBlastsMalignantInd-3

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C14143
    UMLS 2011AA Property
    C0205282
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    Peripheral Platelet Count (/mm3 x 1000)
    Descrição

    Platelets

    Tipo de dados

    float

    Unidades de medida
    • 1000/uL
    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0005821
    NCI Thesaurus Property-2
    C12520
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25712
    1000/uL
    Peripheral Granulocytes Count (AGC/ANC /mm3*)
    Descrição

    Granulocyte count

    Tipo de dados

    float

    Unidades de medida
    • 1000/uL
    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0857490
    NCI Thesaurus Property-2
    C12530
    NCI Thesaurus ValueDomain
    C25463
    NCI Thesaurus ObjectClass
    C25294
    1000/uL
    Clinical Signs and Symptoms of Relapse
    Descrição

    ClinicalLeukemiaRelapseSymptomInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C3161
    UMLS 2011AA ObjectClass
    C0023418
    NCI Thesaurus Property
    C4876
    UMLS 2011AA Property
    C1457887
    If yes, specify
    Descrição

    ClinicalLeukemiaRelapseSymptomSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C3161
    UMLS 2011AA ObjectClass
    C0023418
    NCI Thesaurus Property
    C4876
    UMLS 2011AA Property
    C1457887
    Date of Relapse
    Descrição

    RelapseDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus Property
    C25164
    UMLS 2011AA Property
    C0011008
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C18265
    Comments
    Descrição

    Comments

    Comments
    Descrição

    Research Comments

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Investigator Signature
    Descrição

    Investigator Signature

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    NCI Thesaurus ObjectClass
    C17089
    Investigator Signature Date
    Descrição

    Investigator Signature Date

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    UMLS CUI-2
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C17089

    Similar models

    No Instruction available.

    1. StudyEvent: ECOG Acute Leukemia Disease Assessment Form - Form 1651
      1. No Instruction available.
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    Alias
    Item Group
    Header
    Protocol Number ECOG
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Patient ID ECOG
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1512162 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus Property-2)
    Generic drug form
    Item
    DCI Name (Place ID Label Here)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C3242750 (UMLS CUI-1)
    C19464 (NCI Thesaurus Property)
    C25474 (NCI Thesaurus ObjectClass)
    C25452 (NCI Thesaurus ObjectClass-2)
    Patient Initials
    Item
    Patient Initials (Last, First)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Item
    Report Period
    text
    Code List
    Report Period
    CL Item
    Relapsed (Relapse)
    Data amended
    Item
    Are data amended
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    ECOG Acute Leukemia Assessment
    BoneMarrowBiopsyDate
    Item
    Date of Bone Marrow Biopsy (or Aspirate Confirming relapse)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    C15189 (NCI Thesaurus Property)
    C0005558 (UMLS 2011AA Property)
    C12431 (NCI Thesaurus ObjectClass)
    C0005953 (UMLS 2011AA ObjectClass)
    Blasts, Bone Marrow
    Item
    Marrow Blasts (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C1982687 (UMLS CUI-1)
    C12431 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C12918 (NCI Thesaurus Property-3)
    C25613 (NCI Thesaurus ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    Bone Marrow Cellularity
    Item
    Marrow Cellularity (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C1561532 (UMLS CUI-1)
    C12431 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C37923 (NCI Thesaurus Property-3)
    C25613 (NCI Thesaurus ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    HematologyLabCollectedDate
    Item
    Date Hematology (Blood) Sample Obtained
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus ValueDomain-2)
    PeripheralBloodBlastsMalignantInd-3
    Item
    Peripheral Leukemic blasts
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C14143 (NCI Thesaurus Property)
    C0205282 (UMLS 2011AA Property)
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    Platelets
    Item
    Peripheral Platelet Count (/mm3 x 1000)
    float
    C20200 (NCI Thesaurus Property)
    C0005821 (UMLS CUI-1)
    C12520 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    Granulocyte count
    Item
    Peripheral Granulocytes Count (AGC/ANC /mm3*)
    float
    C20200 (NCI Thesaurus Property)
    C0857490 (UMLS CUI-1)
    C12530 (NCI Thesaurus Property-2)
    C25463 (NCI Thesaurus ValueDomain)
    C25294 (NCI Thesaurus ObjectClass)
    ClinicalLeukemiaRelapseSymptomInd-2
    Item
    Clinical Signs and Symptoms of Relapse
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C4876 (NCI Thesaurus Property)
    C1457887 (UMLS 2011AA Property)
    ClinicalLeukemiaRelapseSymptomSpecify
    Item
    If yes, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C4876 (NCI Thesaurus Property)
    C1457887 (UMLS 2011AA Property)
    RelapseDate
    Item
    Date of Relapse
    date
    C25164 (NCI Thesaurus Property)
    C0011008 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C18265 (NCI Thesaurus ObjectClass)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Investigator Signature
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    Investigator Signature Date
    Item
    Investigator Signature Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25367 (NCI Thesaurus ValueDomain-2)
    C17089 (NCI Thesaurus ObjectClass)

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