ID

11628

Descrição

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

Palavras-chave

  1. 19/09/2012 19/09/2012 -
  2. 09/07/2015 09/07/2015 - Martin Dugas
Transferido a

9 de julho de 2015

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy

Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

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.

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

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

Patient`s Name
Descrição

Patient`s Name

Tipo de dados

text

Alias
UMLS CUI-1
C1299487
Patient Hospital Number
Descrição

PatientHospitalNumber

Tipo de dados

text

Main Member Institution/Adjunct
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroupName

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Participating Group Patient No.
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

CALGB LabTrak number
Descrição

CALGB LabTrak number

Tipo de dados

text

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

SpecimenCollectionDate

Tipo de dados

date

FAB subtype
Descrição

FAB subtype

Tipo de dados

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:)
Descrição

LeukemiaClassification,Other

Tipo de dados

text

Did patient have prior MDS?
Descrição

DidpatienthavepriorMDS?

Tipo de dados

boolean

Is this therapy-related AML?
Descrição

Is this therapy-related AML?

Tipo de dados

text

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

SpecimenCellSource

Tipo de dados

text

Other, specify (source of specimen submitted)
Descrição

SpecimenCellSourceOther

Tipo de dados

text

Type of sample
Descrição

SamplePeriod

Tipo de dados

text

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

SamplePeriod,Other

Tipo de dados

text

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

CBC report (including WBC, hemoglobin, platelet count)

Tipo de dados

boolean

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

Flow cytometry/immunophenotype report

Tipo de dados

boolean

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

Pathology report

Tipo de dados

boolean

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

Cytogenetics report

Tipo de dados

boolean

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

Ifanyabovenamedrequiredreportsarenotsubmitted,specifyreason

Tipo de dados

text

Investigator
Descrição

InvestigatorName

Tipo de dados

text

Completed By
Descrição

CompletedBy

Tipo de dados

text

(Print or Type Name)
Descrição

(PrintorTypeName)

Tipo de dados

text

Date Completed
Descrição

FormCompletionDate,Original

Tipo de dados

date

Phone
Descrição

Phone

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
Fax
Descrição

FaxNumber

Tipo de dados

float

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.

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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
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
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
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

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial