ID

11628

Descripción

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

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 9/7/15 9/7/15 - Martin Dugas
Subido en

9 de julio de 2015

DOI

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Licencia

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

Inglés

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

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

Patient`s Name
Descripción

Patient`s Name

Tipo de datos

text

Alias
UMLS CUI-1
C1299487
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroupName

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientID

Tipo de datos

text

CALGB LabTrak number
Descripción

CALGB LabTrak number

Tipo de datos

text

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

SpecimenCollectionDate

Tipo de datos

date

FAB subtype
Descripción

FAB subtype

Tipo de datos

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:)
Descripción

LeukemiaClassification,Other

Tipo de datos

text

Did patient have prior MDS?
Descripción

DidpatienthavepriorMDS?

Tipo de datos

boolean

Is this therapy-related AML?
Descripción

Is this therapy-related AML?

Tipo de datos

text

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

SpecimenCellSource

Tipo de datos

text

Other, specify (source of specimen submitted)
Descripción

SpecimenCellSourceOther

Tipo de datos

text

Type of sample
Descripción

SamplePeriod

Tipo de datos

text

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

SamplePeriod,Other

Tipo de datos

text

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

CBC report (including WBC, hemoglobin, platelet count)

Tipo de datos

boolean

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

Flow cytometry/immunophenotype report

Tipo de datos

boolean

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

Pathology report

Tipo de datos

boolean

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

Cytogenetics report

Tipo de datos

boolean

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

Ifanyabovenamedrequiredreportsarenotsubmitted,specifyreason

Tipo de datos

text

Investigator
Descripción

InvestigatorName

Tipo de datos

text

Completed By
Descripción

CompletedBy

Tipo de datos

text

(Print or Type Name)
Descripción

(PrintorTypeName)

Tipo de datos

text

Date Completed
Descripción

FormCompletionDate,Original

Tipo de datos

date

Phone
Descripción

Phone

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
Fax
Descripción

FaxNumber

Tipo de datos

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 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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