ID

11628

Description

CALGB: DIAGNOSTIC BLOOD/BONE MARROW EVALUATION FORM Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B228F576-D49A-4DCD-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B228F576-D49A-4DCD-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/9/15 7/9/15 - Martin Dugas
Uploaded on

July 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia Lab BLOOD/BONE MARROW EVALUATION FORM 2076614v3.0 NCT00085124

English

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms  
Ccrr Module For Calgb: Diagnostic Blood/bone Marrow Evaluation Form
Description

Ccrr Module For Calgb: Diagnostic Blood/bone Marrow Evaluation Form

Patient`s Name
Description

Patient`s Name

Data type

text

Alias
UMLS CUI-1
C1299487
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Data type

text

Participating Group
Description

ParticipatingGroupName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientID

Data type

text

CALGB LabTrak number
Description

CALGB LabTrak number

Data type

text

Alias
UMLS CUI-1
C1299222
Date sample obtained (M D Y)
Description

SpecimenCollectionDate

Data type

date

FAB subtype
Description

FAB subtype

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C3161
NCI Thesaurus Property
C25161
UMLS CUI-1
C2984084
Other, specify (diagnosis) (If diagnosed with AML:)
Description

LeukemiaClassification,Other

Data type

text

Did patient have prior MDS?
Description

DidpatienthavepriorMDS?

Data type

boolean

Is this therapy-related AML?
Description

Is this therapy-related AML?

Data type

text

Source of specimen submitted (specimens must be submitted within one week of date sample obtained)
Description

SpecimenCellSource

Data type

text

Other, specify (source of specimen submitted)
Description

SpecimenCellSourceOther

Data type

text

Type of sample
Description

SamplePeriod

Data type

text

Other, specify (type of sample) (The following required reports are attached to this form)
Description

SamplePeriod,Other

Data type

text

CBC report (including WBC, hemoglobin, platelet count)
Description

CBC report (including WBC, hemoglobin, platelet count)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0009555
Flow cytometry/immunophenotype report
Description

Flow cytometry/immunophenotype report

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0016263
UMLS CUI-2
C0079611
Pathology report
Description

Pathology report

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25375
NCI Thesaurus ObjectClass
C18189
UMLS CUI-1
C0807321
Cytogenetics report
Description

Cytogenetics report

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0010802
If any above named required reports are not submitted, specify reason
Description

Ifanyabovenamedrequiredreportsarenotsubmitted,specifyreason

Data type

text

Investigator
Description

InvestigatorName

Data type

text

Completed By
Description

CompletedBy

Data type

text

(Print or Type Name)
Description

(PrintorTypeName)

Data type

text

Date Completed
Description

FormCompletionDate,Original

Data type

date

Phone
Description

Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
Fax
Description

FaxNumber

Data type

float

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Similar models

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb: Diagnostic Blood/bone Marrow Evaluation Form
PatientName
Item
Patient`s Name
text
C1299487 (UMLS CUI-1)
PatientHospitalNumber
Item
Patient Hospital Number
text
MainMemberInstitution/Affiliate
Item
Main Member Institution/Adjunct
text
ParticipatingGroupName
Item
Participating Group
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
SpecimenID
Item
CALGB LabTrak number
text
C1299222 (UMLS CUI-1)
SpecimenCollectionDate
Item
Date sample obtained (M D Y)
date
Leukemia MDS Classification
Item
FAB subtype
text
C25372 (NCI Thesaurus ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C2984084 (UMLS CUI-1)
LeukemiaClassification,Other
Item
Other, specify (diagnosis) (If diagnosed with AML:)
text
DidpatienthavepriorMDS?
Item
Did patient have prior MDS?
boolean
Item
Is this therapy-related AML?
text
CL.3
Code List
Is this therapy-related AML?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
CL Item
Possibly (Possibly)
C0332149 (UMLS CUI-1)
Item
Source of specimen submitted (specimens must be submitted within one week of date sample obtained)
text
CL.4
Code List
Source of specimen submitted (specimens must be submitted within one week of date sample obtained)
CL Item
Bone Marrow (Bone marrow)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Peripheral Blood (Peripheral blood)
C0229664 (NCI Metathesaurus)
CL Item
Other, Specify (Other, specify)
SpecimenCellSourceOther
Item
Other, specify (source of specimen submitted)
text
Item
Type of sample
text
CL.5
Code List
Type of sample
CL Item
Sample Or Specimen Collected Before Patient Received Treatment For Cancer (Pretreatment)
CL Item
Complete response (Complete response)
CL Item
Relapse (Relapse)
CL Item
Other, Specify (Other, specify)
SamplePeriod,Other
Item
Other, specify (type of sample) (The following required reports are attached to this form)
text
CBC
Item
CBC report (including WBC, hemoglobin, platelet count)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0009555 (UMLS CUI-1)
Flowcytometry immunophenotype
Item
Flow cytometry/immunophenotype report
boolean
C38148 (NCI Thesaurus ValueDomain)
C0016263 (UMLS CUI-1)
C0079611 (UMLS CUI-2)
Pathology report
Item
Pathology report
boolean
C38148 (NCI Thesaurus ValueDomain)
C25375 (NCI Thesaurus Property)
C18189 (NCI Thesaurus ObjectClass)
C0807321 (UMLS CUI-1)
Cytogenetics report
Item
Cytogenetics report
boolean
C38148 (NCI Thesaurus ValueDomain)
C0010802 (UMLS CUI-1)
Ifanyabovenamedrequiredreportsarenotsubmitted,specifyreason
Item
If any above named required reports are not submitted, specify reason
text
InvestigatorName
Item
Investigator
text
CompletedBy
Item
Completed By
text
(PrintorTypeName)
Item
(Print or Type Name)
text
FormCompletionDate,Original
Item
Date Completed
date
Person Completing Form Phone
Item
Phone
text
C25704 (NCI Thesaurus ValueDomain)
FaxNumber
Item
Fax
float
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