ID

1925

Description

CALGB: C-1001 NEW PRIMARY CANCER 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=B229FEB2-6C43-5155-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229FEB2-6C43-5155-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 27/07/2017 27/07/2017 - Martin Dugas
Téléchargé le

19 septembre 2012

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
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Leukemia NCT00085124 Follow-Up - CALGB: C-1001 NEW PRIMARY CANCER FORM - 2076934v3.0

Anglais

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 Formulaires  
Ccrr Module For Calgb: C-1001 New Primary Cancer Form
Description

Ccrr Module For Calgb: C-1001 New Primary Cancer Form

CALGB Form
Description

CALGBForm

Type de données

text

CALGB Study No
Description

CALGBProtocolNumber

Type de données

text

CALGB Patient ID
Description

CALGBPatientID

Type de données

text

Are data amended
Description

AmendedDataInd

Type de données

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient?s Name
Description

Patient'sName

Type de données

text

Patient Hospital Number
Description

PatientHospitalNumber

Type de données

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Type de données

text

Participating Group
Description

ParticipatingGroupName

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Participating Group Patient No.
Description

ParticipatingGroupPatientID

Type de données

text

Site(s) of New Primary
Description

NewCancerSiteText

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25586
UMLS 2011AA ObjectClass
C0205314
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
New Primary, Histologic Type
Description

NewPrimary,HistologicType

Type de données

text

Date of Diagnosis
Description

NewCancerDiagnosisDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Comments
Description

ResearchCommentsText

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Completed by (First Name. Last Name)
Description

CompletedBy

Type de données

text

Date Form Completed (Y Y Y Y D D M M)
Description

FormOriginalCompleteDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
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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 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Ccrr Module For Calgb: C-1001 New Primary Cancer Form
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Are data amended
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient?s Name
text
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
NewCancerSiteText
Item
Site(s) of New Primary
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
NewPrimary,HistologicType
Item
New Primary, Histologic Type
text
NewCancerDiagnosisDate
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
CompletedBy
Item
Completed by (First Name. Last Name)
text
FormOriginalCompleteDate
Item
Date Form Completed (Y Y Y Y D D M M)
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
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