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ID
11628
Beschrijving
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
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Versies (2)
- 19-09-12 19-09-12 -
- 09-07-15 09-07-15 - Martin Dugas
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9 juli 2015
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Creative Commons BY-NC 3.0 Legacy
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Leukemia Lab BLOOD/BONE MARROW EVALUATION FORM 2076614v3.0 NCT00085124
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.
- StudyEvent: CALGB: DIAGNOSTIC BLOOD/BONE MARROW EVALUATION FORM
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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.
- StudyEvent: CALGB: DIAGNOSTIC BLOOD/BONE MARROW EVALUATION FORM
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
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)
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
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
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
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)
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
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)
C0009555 (UMLS CUI-1)
Flowcytometry immunophenotype
Item
Flow cytometry/immunophenotype report
boolean
C38148 (NCI Thesaurus ValueDomain)
C0016263 (UMLS CUI-1)
C0079611 (UMLS CUI-2)
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)
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)
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