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Case Report Form (CRF)

1 forms  
  1. StudyEvent: ODM
    1. Case Report Form (CRF)
Blood Sample Collection
Description

Blood Sample Collection

Date of sample
Description

Date of sample

Data type

date

Alias
UMLS CUI [1]
C0460065
Physician Information
Description

Physician Information

Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0421448
Affiliation
Description

Affiliation

Data type

integer

Alias
UMLS CUI [1]
C0029239
City
Description

City

Data type

integer

Alias
UMLS CUI [1]
C0008848
Country
Description

Country

Data type

integer

Alias
UMLS CUI [1]
C0454664
Patient Information
Description

Patient Information

Initials
Description

first name / last name

Data type

integer

Alias
UMLS CUI [1]
C2986440
Date of Birth
Description

Month Year

Data type

integer

Alias
UMLS CUI [1]
C0421451
Sex
Description

Sex

Data type

integer

Alias
UMLS CUI [1]
C0079399
Ethnicity
Description

Ethnic Group

Data type

integer

Alias
UMLS CUI [1]
C0015031
Date of informed consent
Description

Date of informed consent

Data type

date

Alias
UMLS CUI [1]
C2985782
Type of BCR-ABL transcript at diagnosis
Description

Type of BCR-ABL transcript at diagnosis

Data type

integer

Alias
UMLS CUI [1]
C0004891
Eutos Score (at diagnosis)
Description

Eutos Score (at diagnosis)

Data type

integer

Alias
UMLS CUI [1]
C0449820
Sokal Score (at diagnosis)
Description

Sokal Score (at diagnosis)

Data type

integer

Alias
UMLS CUI [1]
C0449820
Euro (Hasford) Score (at diagnosis)
Description

Euro (Hasford) Score (at diagnosis)

Data type

integer

Alias
UMLS CUI [1]
C0449820
CML Diagnosis, Treatment
Description

CML Diagnosis, Treatment

CML Diagnosis
Description

CML Diagnosis

Data type

date

Alias
UMLS CUI [1]
C0279899
First line TKI
Description

Start Stop Onging

Data type

integer

Alias
UMLS CUI [1,1]
C0879484
UMLS CUI [1,2]
C1708063
Second line TKI
Description

Reason for regimen change (to second line): drug resistance intolerance

Data type

integer

Alias
UMLS CUI [1,1]
C0879484
UMLS CUI [1,2]
C1710038
Third line TKI
Description

Reason for regimen change (to third line): drug resistance intolerance

Data type

integer

Alias
UMLS CUI [1,1]
C2986605
UMLS CUI [1,2]
C0879484
Current treatment
Description

Current treatment

Data type

integer

Measurement units
  • mg/day
Alias
UMLS CUI [1]
C1522541
Most recent molecular result from the local lab
Description

Judgement of molecular result from the local lab

Data type

integer

Alias
UMLS CUI [1,1]
C1521991
UMLS CUI [1,2]
C0587081
Date & Signature
Description

Date & Signature

Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Sign./Physician Stamp
Description

Sign./Physician Stamp

Data type

integer

Alias
UMLS CUI [1]
C1519316
Addresses of reference laboratories
Description

Addresses of reference laboratories

How to send samples
Description

Data to be sent from the referring physician to the laboratory Required: 20-30 mlperipheral blood (EDTA). Please favour days from monday to thursday for sending the samples in.

Data type

integer

Alias
UMLS CUI [1,1]
C0229664
UMLS CUI [1,2]
C0878557
Universitätsklinikum Jena
Description

Medizinische Universitäts-Laboratorien Hämatologisch-onkologisches Speziallabor Postfach 100236 07702 Jena

Data type

integer

Alias
UMLS CUI [1,1]
C0000872
UMLS CUI [1,2]
C1442065
Universitätsklinikum Leipzig
Description

Wissenschaftliches Labor III. Medizinische Klinik Universitätsmedizin Mannheim Pettenkoferstr. 22 68169 Mannheim

Data type

integer

Alias
UMLS CUI [1,1]
C0000872
UMLS CUI [1,2]
C1442065
Universtitätsklinik Mannheim
Description

Wissenschaftliches Labor III. Medizinische Klinik Universitätsmedizin Mannheim Pettenkoferstr. 22 68169 Mannheim

Data type

integer

Alias
UMLS CUI [1,1]
C0000872
UMLS CUI [1,2]
C1442065
Universitätsklinikum Schleswig-Holstein, Campus Kiel
Description

Labor für Hämatologische Spezialdiagnostik II. Medizinische Klinik Universitätsklinikum Schleswig-Holstein, Campus Kiel Im Städtischen Krankenhaus Chemnitzstrasse 33 24116 Kiel

Data type

integer

Alias
UMLS CUI [1,1]
C0000872
UMLS CUI [1,2]
C1442065
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Similar models

Case Report Form (CRF)

1 forms
  1. StudyEvent: ODM
    1. Case Report Form (CRF)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Blood Sample Collection
Date of sample
Item
Date of sample
date
C0460065 (UMLS CUI [1])
Item Group
Physician Information
Name
Item
Name
text
C0421448 (UMLS CUI [1])
Item
Affiliation
integer
C0029239 (UMLS CUI [1])
Affiliation
Code List
Affiliation
CL Item
academic (1)
C0000872 (UMLS CUI-1)
CL Item
regional hospital (2)
C0034971 (UMLS CUI-1)
CL Item
office based hematologist (3)
C0278598 (UMLS CUI-1)
City
Item
City
integer
C0008848 (UMLS CUI [1])
Country
Item
Country
integer
C0454664 (UMLS CUI [1])
Item Group
Patient Information
Initialen
Item
Initials
integer
C2986440 (UMLS CUI [1])
Date of Birth
Item
Date of Birth
integer
C0421451 (UMLS CUI [1])
Item
Sex
integer
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
Male (1)
C1706180 (UMLS CUI-1)
CL Item
Female (2)
C0015780 (UMLS CUI-1)
Item
Ethnicity
integer
C0015031 (UMLS CUI [1])
Ethnic Group
Code List
Ethnicity
CL Item
Caucasian (1)
C0007457 (UMLS CUI-1)
CL Item
Black (2)
C0005680 (UMLS CUI-1)
CL Item
Hispanic (3)
C0086409 (UMLS CUI-1)
CL Item
Oriental/Asian (4)
C0078988 (UMLS CUI-1)
CL Item
Other (5)
C0205394 (UMLS CUI-1)
Date of informed consent
Item
Date of informed consent
date
C2985782 (UMLS CUI [1])
Item
Type of BCR-ABL transcript at diagnosis
integer
C0004891 (UMLS CUI [1])
Type of BCR-ABL transcript at diagnosis
Code List
Type of BCR-ABL transcript at diagnosis
CL Item
b2a2 (e13a2) (1)
C1955180 (UMLS CUI-1)
CL Item
b3a2 (e14a2) (2)
C1955181 (UMLS CUI-1)
CL Item
b2a2 + b3a2 (e13a2 + e14a2) (3)
C2709110 (UMLS CUI-1)
CL Item
e1a2 (4)
C2963376 (UMLS CUI-1)
CL Item
b2a3 (e13a3) (5)
CL Item
b3a3 (e14a3) (6)
CL Item
e6a2 (7)
C0029006 (UMLS CUI-1)
CL Item
e19a2 (8)
C2707995 (UMLS CUI-1)
CL Item
unknown (9)
C0439673 (UMLS CUI-1)
CL Item
Other (10)
C0205394 (UMLS CUI-1)
Item
Eutos Score (at diagnosis)
integer
C0449820 (UMLS CUI [1])
Eutos Score (at diagnosis)
Code List
Eutos Score (at diagnosis)
CL Item
high (1)
C1561957 (UMLS CUI-1)
CL Item
low (2)
C0205251 (UMLS CUI-1)
Item
Sokal Score (at diagnosis)
integer
C0449820 (UMLS CUI [1])
Sokal Score (at diagnosis)
Code List
Sokal Score (at diagnosis)
CL Item
low (low)
C0205251 (UMLS CUI-1)
CL Item
intermediate (intermediate)
C0205103 (UMLS CUI-1)
CL Item
high (high)
C0205250 (UMLS CUI-1)
Item
Euro (Hasford) Score (at diagnosis)
integer
C0449820 (UMLS CUI [1])
Euro (Hasford) Score (at diagnosis)
Code List
Euro (Hasford) Score (at diagnosis)
CL Item
low (1)
C0205251 (UMLS CUI-1)
CL Item
intermediate (2)
C0205103 (UMLS CUI-1)
CL Item
high (3)
C0205250 (UMLS CUI-1)
Item Group
CML Diagnosis, Treatment
CML Diagnosis
Item
CML Diagnosis
date
C0279899 (UMLS CUI [1])
Item
First line TKI
integer
C0879484 (UMLS CUI [1,1])
C1708063 (UMLS CUI [1,2])
First line TKI
Code List
First line TKI
CL Item
Imatinib (1)
C0935989 (UMLS CUI-1)
CL Item
Nilotinib (2)
C1721377 (UMLS CUI-1)
CL Item
Dasatinib  (3)
C1455147 (UMLS CUI-1)
CL Item
Bosutinib  (4)
C1831731 (UMLS CUI-1)
CL Item
Ponatinib (5)
C2987417 (UMLS CUI-1)
Item
Second line TKI
integer
C0879484 (UMLS CUI [1,1])
C1710038 (UMLS CUI [1,2])
Second line TKI
Code List
Second line TKI
CL Item
Imatinib (1)
CL Item
Nilotinib (2)
CL Item
Dasatinib (3)
CL Item
Bosutinib (4)
CL Item
Ponatinib (5)
Item
Third line TKI
integer
C2986605 (UMLS CUI [1,1])
C0879484 (UMLS CUI [1,2])
Third line TKI
Code List
Third line TKI
CL Item
Imatinib (1)
C0935989 (UMLS CUI-1)
CL Item
Nilotinib  (2)
C1721377 (UMLS CUI-1)
CL Item
Dasatinib  (3)
C1455147 (UMLS CUI-1)
CL Item
Bosutinib  (4)
C1831731 (UMLS CUI-1)
CL Item
Ponatinib (5)
C2987417 (UMLS CUI-1)
Item
Current treatment
integer
C1522541 (UMLS CUI [1])
Current treatment
Code List
Current treatment
CL Item
Imatinib  (1)
C0935989 (UMLS CUI-1)
CL Item
Nilotinib (2)
C1721377 (UMLS CUI-1)
CL Item
Dasatinib (3)
C1455147 (UMLS CUI-1)
CL Item
Bosutinib (4)
C1831731 (UMLS CUI-1)
CL Item
Ponatinib (5)
C2987417 (UMLS CUI-1)
CL Item
Other (6)
C0205394 (UMLS CUI-1)
Item
Most recent molecular result from the local lab
integer
C1521991 (UMLS CUI [1,1])
C0587081 (UMLS CUI [1,2])
Most recent molecular result from the local lab
Code List
Most recent molecular result from the local lab
CL Item
No MMR (1)
CL Item
MMR (2)
CL Item
MR4 (3)
CL Item
MR4.5 (4)
CL Item
MR5 (5)
CL Item
CMR (6)
C0654223 (UMLS CUI-1)
Item Group
Date & Signature
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Sign./Physician Stamp
Item
Sign./Physician Stamp
integer
C1519316 (UMLS CUI [1])
Item Group
Addresses of reference laboratories
How to send samples
Item
How to send samples
integer
C0229664 (UMLS CUI [1,1])
C0878557 (UMLS CUI [1,2])
Universitätsklinikum Jena
Item
Universitätsklinikum Jena
integer
C0000872 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Item
Universitätsklinikum Leipzig
integer
C0000872 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Universitätsklinikum Leipzig
Code List
Universitätsklinikum Leipzig
Item
Universtitätsklinik Mannheim
integer
C0000872 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Universtitätsklinik Mannheim
Code List
Universtitätsklinik Mannheim
Universitätsklinikum Schleswig-Holstein, Campus Kiel
Item
Universitätsklinikum Schleswig-Holstein, Campus Kiel
integer
C0000872 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
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