ID

11126

Descripción

CALGB-10501 Chronic Lymphocytic Leukemia (CLL) On-Study Form NCT00513747 Early or Delayed Fludarabine and Rituximab in Treating Patients With Previously Untreated Chronic Lymphocytic Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3410113C-1559-25BC-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3410113C-1559-25BC-E044-0003BA3F9857

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 21/6/15 21/6/15 -
Subido en

21 de junio de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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CALGB-10501 Chronic Lymphocytic Leukemia (CLL) On-Study Form NCT00513747

Inglés

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 formularios  
Header
Descripción

Header

CALGB Form
Descripción

Form ID CALGB

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3262252
NCI Thesaurus ObjectClass
C19464
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C25442
CALGB Study No
Descripción

Protocol ID CALGB

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
CALGB Patient ID
Descripción

Trial subject ID CALGB

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1516238
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25442
Are data amended
Descripción

Data amended

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Patient demographics
Descripción

Patient demographics

Patient Initials (Last, First Middle)
Descripción

Patient Initials

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Hospital No.
Descripción

Medical Record Number

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301894
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25261
NCI Thesaurus Property-2
C25198
Institution/Affiliate
Descripción

Institution Name

Tipo de datos

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
Participating Group
Descripción

Participating Group

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2347449
NCI Thesaurus ObjectClass
C25608
NCI Thesaurus ObjectClass-2
C17005
NCI Thesaurus Property
C25364
Participating Group Study No
Descripción

Study Number Participating Group

Tipo de datos

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
Descripción

Trial subject ID Participating Group

Tipo de datos

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
Patient status assessment
Descripción

Patient status assessment

MedDRA Code
Descripción

MedDRACode

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Metathesaurus ObjectClass
CL104089
Date of Initial Pathologic Diagnosis (MM DD YYYY)
Descripción

CancerInitialDiagnosisDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Height (cm)
Descripción

Patient Height

Tipo de datos

float

Unidades de medida
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS CUI-1
C0489786
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25347
cm
Weight (kg)
Descripción

Patient Weight

Tipo de datos

float

Unidades de medida
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
UMLS CUI-1
C0005910
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25208
Kg
BSA (m^2)
Descripción

Body Surface Area

Tipo de datos

float

Unidades de medida
  • m2
Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C0005902
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus Property
C25157
m2
Was an abdominal CT performed
Descripción

AbdominalCavityComputedTomographyDiagnosticImagingPerformedInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus ObjectClass-2
C17204
UMLS 2011AA ObjectClass-2
C0040405
NCI Thesaurus ObjectClass-3
C12664
UMLS 2011AA ObjectClass-3
C0230168
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Size of Largest Lymph Node
Descripción

LargestLymphNodeSizeStatus

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus ObjectClass-2
C25550
UMLS 2011AA ObjectClass-2
C0443228
NCI Thesaurus Property
C25681
UMLS 2011AA Property
C0456389
Does the patient have a history of bug bite hypersensitivity
Descripción

PatientInsectHypersensitivityPersonalMedicalHistoryInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3114
UMLS 2011AA Property
C0020517
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
NCI Thesaurus Property-3
C14227
UMLS 2011AA Property-3
C0021585
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Military Service Type (Mark all that apply with an X.)
Descripción

PersonMilitaryServicePerformedType

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property-2
C68638
UMLS 2011AA Property-2
C0026126
NCI Thesaurus Property-3
C47920
UMLS 2011AA Property-3
C0557854
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Has the patient taken antibiotics? (last year)
Descripción

AntibioticAdministeredInd-3

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C258
UMLS 2011AA ObjectClass
C0003232
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Did the patient require hospitalization (last year)
Descripción

PatientHospitalizationInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25179
UMLS 2011AA Property
C0019993
Does the patient have a history of varicella zoster
Descripción

PatientHerpesZosterPersonalMedicalHistoryInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0019360
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
Rai Stage Classification
Descripción

Rai Stage Classification

Rai Stage Classification (Mark one with an X.)
Descripción

CLLLeukemiaRAIStage

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus ObjectClass-2
C3163
UMLS 2011AA ObjectClass-2
C0023434
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
NCI Thesaurus Property-2
C20115
UMLS 2011AA Property-2
C1514715
NCI Thesaurus ValueDomain
C16899
UMLS 2011AA ValueDomain
C1300072
Blood Or Platelet Transfusions
Descripción

Blood Or Platelet Transfusions

Total number of units PRBC (given during the three-month period prior to starting therapy)
Descripción

PackedRedBloodCellTransfusionReceivedUnitCount

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Thesaurus ObjectClass
C15409
UMLS 2011AA ObjectClass
C0199962
Total number of units platelets (given during the three-month period prior to starting therapy)
Descripción

PlateletTransfusionReceivedUnitCount

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
NCI Thesaurus ObjectClass
C15366
UMLS 2011AA ObjectClass
C0086818
Organ Involvement
Descripción

Organ Involvement

Palpable splenomegaly
Descripción

SplenomegalyPalpationDocumentedInd

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C16950
UMLS 2011AA Property
C0030247
NCI Thesaurus ObjectClass
C3384
UMLS 2011AA ObjectClass
C0038002
NCI Thesaurus ValueDomain-2
C25356
UMLS 2011AA ValueDomain-2
C1301725
Splenomegaly by scan (or X-ray)
Descripción

SplenomegalyImageDocumentedInd

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C3384
UMLS 2011AA ObjectClass
C0038002
NCI Thesaurus Property
C19477
UMLS 2011AA Property
C1704254
NCI Thesaurus ValueDomain-2
C25356
UMLS 2011AA ValueDomain-2
C1301725
Date of Splenectomy (MM DD YYYY)
Descripción

PriorSplenectomyDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25629
UMLS 2011AA ObjectClass
C0332152
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ObjectClass-2
C15328
UMLS 2011AA ObjectClass-2
C0037995
Palpable hepatomegaly
Descripción

HepatomegalyPalpationDocumentedInd

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C16950
UMLS 2011AA Property
C0030247
NCI Thesaurus ObjectClass
C3100
UMLS 2011AA ObjectClass
C0017924
NCI Thesaurus ValueDomain-2
C25356
UMLS 2011AA ValueDomain-2
C1301725
Hepatomegaly by scan (or X-ray)
Descripción

HepatomegalyImageDocumentedInd

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C3100
UMLS 2011AA ObjectClass
C0017924
NCI Thesaurus Property
C19477
UMLS 2011AA Property
C1704254
NCI Thesaurus ValueDomain-2
C25356
UMLS 2011AA ValueDomain-2
C1301725
Lymph Node Involvement
Descripción

Lymph Node Involvement

Is there lymph node involvement (If Yes, complete the following)
Descripción

LymphNodeInvolvementInd-3

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus Property
C25547
Number of Positive Lymph Nodes
Descripción

LymphNodePositiveCount

Tipo de datos

float

Alias
NCI Thesaurus Property
C25246
UMLS 2011AA Property
C1446409
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Any lymph node or aggregate with a diameter greater than 10 cm (if pediatric, >6 cm)
Descripción

LymphomaLymphNodeLargeDiameterIndicator

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ObjectClass-2
C3208
UMLS 2011AA ObjectClass-2
C0024299
NCI Thesaurus Property
C25285
UMLS 2011AA Property
C1301886
NCI Thesaurus Property-2
C49508
UMLS 2011AA Property-2
C0549177
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Any lymph node or aggregate with a diameter greater than 5 cm
Descripción

LymphomaLymphNodeMediumDiameterInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ObjectClass-2
C3208
UMLS 2011AA ObjectClass-2
C0024299
NCI Thesaurus Property
C25285
UMLS 2011AA Property
C1301886
NCI Thesaurus Property-2
C49507
UMLS 2011AA Property-2
C0439536
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Any lymph node or aggregate with a diameter >2 cm
Descripción

LymphomaLymphNodeSmallMediumDiameterIndicator

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ObjectClass-2
C3208
UMLS 2011AA ObjectClass-2
C0024299
NCI Thesaurus Property
C25285
UMLS 2011AA Property
C1301886
NCI Thesaurus Property-2
C49507
UMLS 2011AA Property-2
C0439536
NCI Thesaurus Property-3
C25376
UMLS 2011AA Property-3
C0700321
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Any lymph node or aggregate with a diameter >1 cm but <2 cm
Descripción

LymphomaLymphNodeSmallDiameterIndicator

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ObjectClass-2
C3208
UMLS 2011AA ObjectClass-2
C0024299
NCI Thesaurus Property
C25285
UMLS 2011AA Property
C1301886
NCI Thesaurus Property-2
C25376
UMLS 2011AA Property-2
C0700321
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Lab Data/values
Descripción

Lab Data/values

Creatinine (mg/dl)
Descripción

RenalCreatinineLabSpecifiedValue

Tipo de datos

float

Unidades de medida
  • mg/dL
Alias
NCI Thesaurus ObjectClass
C25225
UMLS 2011AA ObjectClass
C0022646
NCI Thesaurus Property
C399
UMLS 2011AA Property
C0010294
NCI Thesaurus Property-2
C25294
UMLS 2011AA Property-2
C0022885
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
mg/dL
Creatinine ULN (mg/dl)
Descripción

Creatinine, serum ULN

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201976
NCI Thesaurus Property
C20200
UMLS CUI-2
C1519815
NCI Thesaurus Property-2
C399
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
Lactate Dehydrogenase (LDH) (U/L)
Descripción

LDH

Tipo de datos

float

Unidades de medida
  • U/L
Alias
NCI Thesaurus Property
C20200
UMLS CUI-1
C0202113
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus Property-2
C25184
U/L
Lactate Dehydrogenase ULN (U/L)
Descripción

LDH ULN

Tipo de datos

float

Unidades de medida
  • U/L
Alias
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0202113
NCI Thesaurus Property
C20200
UMLS CUI-2
C1519815
NCI Thesaurus Property-2
C25184
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C38024
NCI Thesaurus ValueDomain-3
C25706
U/L
Beta-2 Microglobulin (mg/liter)
Descripción

LaboratoryProcedureBeta-2-MicroglobulinProteinOutcomeSpecifiedValue

Tipo de datos

float

Alias
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus Property-2
C62657
UMLS 2011AA Property-2
C0005149
Beta-2 Microglobulin ULN (mg/liter)
Descripción

LaboratoryProcedureBeta-2-MicroglobulinProteinOutcomeSpecifiedUpperLimitofNormalValue

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C62657
UMLS 2011AA Property-2
C0005149
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
CMV IgG
Descripción

LaboratoryProcedureAntibodyCytomegalovirusIgGResultStatus

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C14196
UMLS 2011AA Property
C0010825
NCI Thesaurus Property-2
C20200
UMLS 2011AA Property-2
C1274040
NCI Thesaurus Property-3
C568
UMLS 2011AA Property-3
C0020852
NCI Thesaurus Property-4
C16295
UMLS 2011AA Property-4
C0003241
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Varicella IgG
Descripción

LaboratoryProcedureAntibodyHumanHerpesvirus3IgGResultStatus

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C568
UMLS 2011AA Property-2
C0020852
NCI Thesaurus Property-3
C16295
UMLS 2011AA Property-3
C0003241
NCI Thesaurus Property-4
C71091
UMLS 2011AA Property-4
C0042338
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Albumin
Descripción

Albumin

Tipo de datos

float

Alias
NCI Thesaurus Property
C20200
UMLS CUI-1
C0201838
NCI Thesaurus Property-2
C214
NCI Thesaurus ObjectClass
C25294
NCI Thesaurus ValueDomain
C25712
IgG (mg)
Descripción

LaboratoryProcedureSerumImmunologicIgGResultUnspecifiedValue

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C568
UMLS 2011AA Property-2
C0020852
NCI Thesaurus Property-3
C25675
UMLS 2011AA Property-3
C1519267
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
IgA (mg)
Descripción

LaboratoryProcedureSerumImmunologicIgAResultUnspecifiedValue

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C565
UMLS 2011AA Property-2
C0020835
NCI Thesaurus Property-3
C25675
UMLS 2011AA Property-3
C1519267
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
IgM (mg)
Descripción

LaboratoryProcedureSerumImmunologicIgMResultUnspecifiedValue

Tipo de datos

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C569
UMLS 2011AA Property-2
C0020861
NCI Thesaurus Property-3
C25675
UMLS 2011AA Property-3
C1519267
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
Coomb's Test (Mark one with an X.)
Descripción

CoombsTestResultType

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25163
UMLS 2011AA ObjectClass
C0009961
NCI Metathesaurus ObjectClass
C0488535
Coomb's Indirect Test
Descripción

IndirectCoombsTestResultType

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus ObjectClass
C25163
UMLS 2011AA ObjectClass
C0009961
NCI Thesaurus ObjectClass-2
C62255
UMLS 2011AA ObjectClass-2
C0439852
Coomb's Test Date (MM DD YYYY)
Descripción

CoombsTestPerformedDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C25163
UMLS 2011AA ObjectClass
C0009961
NCI Metathesaurus ObjectClass
C0488535
Peripheral CD56 Positive Cells (%)
Descripción

LaboratoryProcedureCD56AntigenOutcomePercentageValue

Tipo de datos

float

Unidades de medida
  • %
Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C17891
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
%
Peripheral CD16 positive cells (%)
Descripción

LaboratoryProcedureFc-GammaReceptorIIIResultPercentageValue

Tipo de datos

float

Unidades de medida
  • %
Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C17487
UMLS 2011AA Property-2
C0108747
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
%
Peripheral CD4 positive cells (%)
Descripción

LaboratoryProcedureCD4-PositiveT-LymphocyteOutcomePercentageValue

Tipo de datos

float

Unidades de medida
  • %
Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C12537
UMLS 2011AA Property-2
C0039215
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
%
Peripheral CD8 positive cells (%)
Descripción

LaboratoryProcedureCD8+cellsOutcomePercentageValue

Tipo de datos

float

Unidades de medida
  • %
Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C12542
UMLS 2011AA Property-2
C0242629
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
%
Peripheral CD19 positive cells (%)
Descripción

LaboratoryProcedureCD19AntigenResultPercentageValue

Tipo de datos

float

Unidades de medida
  • %
Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C38894
UMLS 2011AA Property-2
C0108748
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
%
Chest X-ray Or Thoracic Ct
Descripción

Chest X-ray Or Thoracic Ct

Chest X-Ray Or Thoracic CT (Mark one with an X.)
Descripción

ComputedTomographyX-RayDiagnosticImagingChestThoracicAssessmentStatus

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus ObjectClass-2
C17204
UMLS 2011AA ObjectClass-2
C0040405
NCI Thesaurus ObjectClass-3
C17261
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25389
UMLS 2011AA Property
C0817096
NCI Thesaurus Property-3
C13360
UMLS 2011AA Property-2
C0817096
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Other, specify
Descripción

ComputedTomographyX-RayDiagnosticImagingChestThoracicAssessmentSpecify

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16502
UMLS 2011AA ObjectClass
C0011923
NCI Thesaurus ObjectClass-2
C17204
UMLS 2011AA ObjectClass-2
C0040405
NCI Thesaurus ObjectClass-3
C17261
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C25389
UMLS 2011AA Property
C0817096
NCI Thesaurus Property-3
C13360
UMLS 2011AA Property-2
C0817096
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Footer module
Descripción

Footer module

Completed by (print or type name)
Descripción

Person Completing Form

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date Form Completed (MM DD YYYY)
Descripción

Date Form Completed

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header
Form ID CALGB
Item
CALGB Form
text
C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)
Protocol ID CALGB
Item
CALGB Study No
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
Trial subject ID CALGB
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)
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
Patient demographics
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Medical Record Number
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (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)
Participating Group
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No
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)
Item Group
Patient status assessment
MedDRACode
Item
MedDRA Code
float
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
CancerInitialDiagnosisDate
Item
Date of Initial Pathologic Diagnosis (MM DD YYYY)
date
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Patient Height
Item
Height (cm)
float
C25209 (NCI Thesaurus ValueDomain)
C0489786 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)
Patient Weight
Item
Weight (kg)
float
C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
Body Surface Area
Item
BSA (m^2)
float
C25190 (NCI Thesaurus ObjectClass)
C0005902 (UMLS CUI-1)
C25712 (NCI Thesaurus ValueDomain)
C25157 (NCI Thesaurus Property)
AbdominalCavityComputedTomographyDiagnosticImagingPerformedInd-2
Item
Was an abdominal CT performed
boolean
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C12664 (NCI Thesaurus ObjectClass-3)
C0230168 (UMLS 2011AA ObjectClass-3)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Size of Largest Lymph Node
text
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25550 (NCI Thesaurus ObjectClass-2)
C0443228 (UMLS 2011AA ObjectClass-2)
C25681 (NCI Thesaurus Property)
C0456389 (UMLS 2011AA Property)
CL.18
Code List
Size of Largest Lymph Node
CL Item
> 1 Cm But < 2 Cm (> 1 cm but < 2 cm)
CL Item
>= 2 Cm But < 5 Cm (>= 2 cm but < 5 cm)
CL Item
>= 5 Cm (>= 5 cm)
PatientInsectHypersensitivityPersonalMedicalHistoryInd-2
Item
Does the patient have a history of bug bite hypersensitivity
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3114 (NCI Thesaurus Property)
C0020517 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C14227 (NCI Thesaurus Property-3)
C0021585 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Military Service Type (Mark all that apply with an X.)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C68638 (NCI Thesaurus Property-2)
C0026126 (UMLS 2011AA Property-2)
C47920 (NCI Thesaurus Property-3)
C0557854 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.20
Code List
Military Service Type (Mark all that apply with an X.)
CL Item
Iraq War 1990-1991 (IRAQ War 1990-1991)
CL Item
Iraq War 2001-present (IRAQ War 2001-present)
CL Item
Korean War (Korean War)
CL Item
No Military Service (No military service)
CL Item
Vietnam War (Vietnam War)
AntibioticAdministeredInd-3
Item
Has the patient taken antibiotics? (last year)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C258 (NCI Thesaurus ObjectClass)
C0003232 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
PatientHospitalizationInd-2
Item
Did the patient require hospitalization (last year)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25179 (NCI Thesaurus Property)
C0019993 (UMLS 2011AA Property)
PatientHerpesZosterPersonalMedicalHistoryInd-2
Item
Does the patient have a history of varicella zoster
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0019360 (NCI Metathesaurus Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
Item Group
Rai Stage Classification
Item
Rai Stage Classification (Mark one with an X.)
text
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C3163 (NCI Thesaurus ObjectClass-2)
C0023434 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C20115 (NCI Thesaurus Property-2)
C1514715 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
CL.2
Code List
Rai Stage Classification (Mark one with an X.)
CL Item
Lymphocytosis In Blood With Lymphocyte Count > 15,000/mcl And Bone Marrow Populated With Mature Lymphocytes Comprising >40% Of Nucleated Cells (Stage 0)
CL Item
Same As Stage 0 With Lymphadenopathy (Stage I)
Item Group
Blood Or Platelet Transfusions
PackedRedBloodCellTransfusionReceivedUnitCount
Item
Total number of units PRBC (given during the three-month period prior to starting therapy)
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15409 (NCI Thesaurus ObjectClass)
C0199962 (UMLS 2011AA ObjectClass)
PlateletTransfusionReceivedUnitCount
Item
Total number of units platelets (given during the three-month period prior to starting therapy)
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS 2011AA ObjectClass)
Item Group
Organ Involvement
Item
Palpable splenomegaly
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16950 (NCI Thesaurus Property)
C0030247 (UMLS 2011AA Property)
C3384 (NCI Thesaurus ObjectClass)
C0038002 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus ValueDomain-2)
C1301725 (UMLS 2011AA ValueDomain-2)
CL.3
Code List
Palpable splenomegaly
CL Item
Examination Performed And Splenomegaly Absent (No)
CL Item
Examination Of Spleen Not Performed (Not examined)
CL Item
Spleen Removed Via Prior Surgery (Surgically absent)
CL Item
Examination Performed And Splenomegaly Present (Yes)
Item
Splenomegaly by scan (or X-ray)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3384 (NCI Thesaurus ObjectClass)
C0038002 (UMLS 2011AA ObjectClass)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
C25356 (NCI Thesaurus ValueDomain-2)
C1301725 (UMLS 2011AA ValueDomain-2)
CL.4
Code List
Splenomegaly by scan (or X-ray)
CL Item
Examination Performed And Splenomegaly Absent (No)
CL Item
Examination Of Spleen Not Performed (Not examined)
CL Item
Spleen Removed Via Prior Surgery (Surgically absent)
CL Item
Examination Performed And Splenomegaly Present (Yes)
PriorSplenectomyDate
Item
Date of Splenectomy (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C15328 (NCI Thesaurus ObjectClass-2)
C0037995 (UMLS 2011AA ObjectClass-2)
Item
Palpable hepatomegaly
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16950 (NCI Thesaurus Property)
C0030247 (UMLS 2011AA Property)
C3100 (NCI Thesaurus ObjectClass)
C0017924 (UMLS 2011AA ObjectClass)
C25356 (NCI Thesaurus ValueDomain-2)
C1301725 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Palpable hepatomegaly
CL Item
Examination Performed And Hepatomegaly Absent (No)
CL Item
Examination Of Liver Not Performed (Not examined)
CL Item
Examination Performed And Hepatomegaly Present (Yes)
Item
Hepatomegaly by scan (or X-ray)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3100 (NCI Thesaurus ObjectClass)
C0017924 (UMLS 2011AA ObjectClass)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
C25356 (NCI Thesaurus ValueDomain-2)
C1301725 (UMLS 2011AA ValueDomain-2)
CL.6
Code List
Hepatomegaly by scan (or X-ray)
CL Item
Examination Performed And Hepatomegaly Absent (No)
CL Item
Examination Of Liver Not Performed (Not examined)
CL Item
Examination Performed And Hepatomegaly Present (Yes)
Item Group
Lymph Node Involvement
LymphNodeInvolvementInd-3
Item
Is there lymph node involvement (If Yes, complete the following)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)
LymphNodePositiveCount
Item
Number of Positive Lymph Nodes
float
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
LymphomaLymphNodeLargeDiameterIndicator
Item
Any lymph node or aggregate with a diameter greater than 10 cm (if pediatric, >6 cm)
boolean
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C3208 (NCI Thesaurus ObjectClass-2)
C0024299 (UMLS 2011AA ObjectClass-2)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C49508 (NCI Thesaurus Property-2)
C0549177 (UMLS 2011AA Property-2)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
LymphomaLymphNodeMediumDiameterInd-2
Item
Any lymph node or aggregate with a diameter greater than 5 cm
boolean
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C3208 (NCI Thesaurus ObjectClass-2)
C0024299 (UMLS 2011AA ObjectClass-2)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C49507 (NCI Thesaurus Property-2)
C0439536 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
LymphomaLymphNodeSmallMediumDiameterIndicator
Item
Any lymph node or aggregate with a diameter >2 cm
boolean
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C3208 (NCI Thesaurus ObjectClass-2)
C0024299 (UMLS 2011AA ObjectClass-2)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C49507 (NCI Thesaurus Property-2)
C0439536 (UMLS 2011AA Property-2)
C25376 (NCI Thesaurus Property-3)
C0700321 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
LymphomaLymphNodeSmallDiameterIndicator
Item
Any lymph node or aggregate with a diameter >1 cm but <2 cm
boolean
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C3208 (NCI Thesaurus ObjectClass-2)
C0024299 (UMLS 2011AA ObjectClass-2)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25376 (NCI Thesaurus Property-2)
C0700321 (UMLS 2011AA Property-2)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item Group
Lab Data/values
RenalCreatinineLabSpecifiedValue
Item
Creatinine (mg/dl)
float
C25225 (NCI Thesaurus ObjectClass)
C0022646 (UMLS 2011AA ObjectClass)
C399 (NCI Thesaurus Property)
C0010294 (UMLS 2011AA Property)
C25294 (NCI Thesaurus Property-2)
C0022885 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
Creatinine, serum ULN
Item
Creatinine ULN (mg/dl)
float
C25294 (NCI Thesaurus ObjectClass)
C0201976 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C1519815 (UMLS CUI-2)
C399 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
LDH
Item
Lactate Dehydrogenase (LDH) (U/L)
float
C20200 (NCI Thesaurus Property)
C0202113 (UMLS CUI-1)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C25184 (NCI Thesaurus Property-2)
LDH ULN
Item
Lactate Dehydrogenase ULN (U/L)
float
C25294 (NCI Thesaurus ObjectClass)
C0202113 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C1519815 (UMLS CUI-2)
C25184 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C38024 (NCI Thesaurus ValueDomain-2)
C25706 (NCI Thesaurus ValueDomain-3)
LaboratoryProcedureBeta-2-MicroglobulinProteinOutcomeSpecifiedValue
Item
Beta-2 Microglobulin (mg/liter)
float
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C62657 (NCI Thesaurus Property-2)
C0005149 (UMLS 2011AA Property-2)
LaboratoryProcedureBeta-2-MicroglobulinProteinOutcomeSpecifiedUpperLimitofNormalValue
Item
Beta-2 Microglobulin ULN (mg/liter)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C62657 (NCI Thesaurus Property-2)
C0005149 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Item
CMV IgG
text
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C14196 (NCI Thesaurus Property)
C0010825 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C568 (NCI Thesaurus Property-3)
C0020852 (UMLS 2011AA Property-3)
C16295 (NCI Thesaurus Property-4)
C0003241 (UMLS 2011AA Property-4)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.12
Code List
CMV IgG
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Varicella IgG
text
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C568 (NCI Thesaurus Property-2)
C0020852 (UMLS 2011AA Property-2)
C16295 (NCI Thesaurus Property-3)
C0003241 (UMLS 2011AA Property-3)
C71091 (NCI Thesaurus Property-4)
C0042338 (UMLS 2011AA Property-4)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.13
Code List
Varicella IgG
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Albumin
Item
Albumin
float
C20200 (NCI Thesaurus Property)
C0201838 (UMLS CUI-1)
C214 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
LaboratoryProcedureSerumImmunologicIgGResultUnspecifiedValue
Item
IgG (mg)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C568 (NCI Thesaurus Property-2)
C0020852 (UMLS 2011AA Property-2)
C25675 (NCI Thesaurus Property-3)
C1519267 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
LaboratoryProcedureSerumImmunologicIgAResultUnspecifiedValue
Item
IgA (mg)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C565 (NCI Thesaurus Property-2)
C0020835 (UMLS 2011AA Property-2)
C25675 (NCI Thesaurus Property-3)
C1519267 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
LaboratoryProcedureSerumImmunologicIgMResultUnspecifiedValue
Item
IgM (mg)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C569 (NCI Thesaurus Property-2)
C0020861 (UMLS 2011AA Property-2)
C25675 (NCI Thesaurus Property-3)
C1519267 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
Item
Coomb's Test (Mark one with an X.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25163 (NCI Thesaurus ObjectClass)
C0009961 (UMLS 2011AA ObjectClass)
C0488535 (NCI Metathesaurus ObjectClass)
CL.14
Code List
Coomb's Test (Mark one with an X.)
CL Item
Coomb's Test Performed And Negative Result (Negative)
CL Item
Coomb's Test Performed And Positive Result (Positive)
Item
Coomb's Indirect Test
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25163 (NCI Thesaurus ObjectClass)
C0009961 (UMLS 2011AA ObjectClass)
C62255 (NCI Thesaurus ObjectClass-2)
C0439852 (UMLS 2011AA ObjectClass-2)
CL.15
Code List
Coomb's Indirect Test
CL Item
Coomb's Test Performed And Negative Result (Negative)
CL Item
Coomb's Test Performed And Positive Result (Positive)
CoombsTestPerformedDate
Item
Coomb's Test Date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25163 (NCI Thesaurus ObjectClass)
C0009961 (UMLS 2011AA ObjectClass)
C0488535 (NCI Metathesaurus ObjectClass)
LaboratoryProcedureCD56AntigenOutcomePercentageValue
Item
Peripheral CD56 Positive Cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C17891 (NCI Thesaurus Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureFc-GammaReceptorIIIResultPercentageValue
Item
Peripheral CD16 positive cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C17487 (NCI Thesaurus Property-2)
C0108747 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureCD4-PositiveT-LymphocyteOutcomePercentageValue
Item
Peripheral CD4 positive cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12537 (NCI Thesaurus Property-2)
C0039215 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureCD8+cellsOutcomePercentageValue
Item
Peripheral CD8 positive cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12542 (NCI Thesaurus Property-2)
C0242629 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureCD19AntigenResultPercentageValue
Item
Peripheral CD19 positive cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C38894 (NCI Thesaurus Property-2)
C0108748 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
Item Group
Chest X-ray Or Thoracic Ct
Item
Chest X-Ray Or Thoracic CT (Mark one with an X.)
text
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C17261 (NCI Thesaurus ObjectClass-3)
C25367 (NCI Thesaurus Property)
C25389 (NCI Thesaurus Property-2)
C0817096 (UMLS 2011AA Property)
C13360 (NCI Thesaurus Property-3)
C0817096 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.16
Code List
Chest X-Ray Or Thoracic CT (Mark one with an X.)
CL Item
Abnormal Mediastinal Enlargement (hilar/paratracheal) (Abnormal mediastinal enlargement (hilar/paratracheal))
CL Item
Abnormal, Interstitial Disease In Lung (Abnormal, interstitial disease in lung)
CL Item
Abnormal, Nodules In Lung Parenchyma (Abnormal, nodules in lung parenchyma)
CL Item
Abnormal, Other (Abnormal, other)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
ComputedTomographyX-RayDiagnosticImagingChestThoracicAssessmentSpecify
Item
Other, specify
text
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C17261 (NCI Thesaurus ObjectClass-3)
C25367 (NCI Thesaurus Property)
C25389 (NCI Thesaurus Property-2)
C0817096 (UMLS 2011AA Property)
C13360 (NCI Thesaurus Property-3)
C0817096 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Footer module
Person Completing Form
Item
Completed by (print or type name)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Date Form Completed
Item
Date Form Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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