ID

1951

Description

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

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/9/15 7/9/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

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

English

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

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

Patient?s Name
Description

Patient'sName

Data type

text

Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Data type

text

Participating Group
Description

ParticipatingGroupName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientID

Data type

text

CALGB LabTrak number
Description

SpecimenID

Data type

double

Date sample obtained (M D Y)
Description

SpecimenCollectionDate

Data type

date

Other, specify (diagnosis) (If diagnosed with AML:)
Description

LeukemiaClassification,Other

Data type

text

Did patient have prior MDS?
Description

DidpatienthavepriorMDS?

Data type

text

Is this therapy-related AML?
Description

Isthistherapy-relatedAML?

Data type

text

FAB subtype
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
FAB subtype
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
FAB subtype
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Source of specimen submitted (specimens must be submitted within one week of date sample obtained)
Description

SpecimenCellSource

Data type

text

Other, specify (source of specimen submitted)
Description

SpecimenCellSourceOther

Data type

text

Type of sample
Description

SamplePeriod

Data type

text

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

SamplePeriod,Other

Data type

text

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

CBCreport(includingWBC,hemoglobin,plateletcount)

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Flow cytometry/immunophenotype report
Description

Flowcytometry/immunophenotypereport

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Pathology report
Description

Pathologyreport

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25375
UMLS 2011AA Property
C0684224
NCI Thesaurus ObjectClass
C18189
UMLS 2011AA ObjectClass
C0030664
Cytogenetics report
Description

Cytogeneticsreport

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
If any above named required reports are not submitted, specify reason
Description

Ifanyabovenamedrequiredreportsarenotsubmitted,specifyreason

Data type

text

Investigator
Description

InvestigatorName

Data type

text

Completed By
Description

CompletedBy

Data type

text

(Print or Type Name)
Description

(PrintorTypeName)

Data type

text

Date Completed
Description

FormCompletionDate,Original

Data type

date

Phone
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Fax
Description

FaxNumber

Data type

double

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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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb: Diagnostic Blood/bone Marrow Evaluation Form
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
SpecimenID
Item
CALGB LabTrak number
double
SpecimenCollectionDate
Item
Date sample obtained (M D Y)
date
LeukemiaClassification,Other
Item
Other, specify (diagnosis) (If diagnosed with AML:)
text
Item
Did patient have prior MDS?
text
CL.2
Code List
Did patient have prior MDS?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Possibly (Possibly)
Leukemia/MDSClassification
Item
FAB subtype
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Leukemia/MDSClassification
Item
FAB subtype
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Leukemia/MDSClassification
Item
FAB subtype
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
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
Item
CBC report (including WBC, hemoglobin, platelet count)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.6
Code List
CBC report (including WBC, hemoglobin, platelet count)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Flow cytometry/immunophenotype report
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.7
Code List
Flow cytometry/immunophenotype report
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Pathology report
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
C18189 (NCI Thesaurus ObjectClass)
C0030664 (UMLS 2011AA ObjectClass)
CL.8
Code List
Pathology report
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Cytogenetics report
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.9
Code List
Cytogenetics report
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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
PersonCompletingForm,Phone
Item
Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
FaxNumber
Item
Fax
double
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