Inglês

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 Formulários  
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'sName

Tipo de dados

text

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

SpecimenID

Tipo de dados

double

Date sample obtained (M D Y)
Descrição

SpecimenCollectionDate

Tipo de dados

date

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

LeukemiaClassification,Other

Tipo de dados

text

Did patient have prior MDS?
Descrição

DidpatienthavepriorMDS?

Tipo de dados

text

Is this therapy-related AML?
Descrição

Isthistherapy-relatedAML?

Tipo de dados

text

FAB subtype
Descrição

Leukemia/MDSClassification

Tipo de dados

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
Descrição

Leukemia/MDSClassification

Tipo de dados

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
Descrição

Leukemia/MDSClassification

Tipo de dados

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)
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

CBCreport(includingWBC,hemoglobin,plateletcount)

Tipo de dados

text

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

Flowcytometry/immunophenotypereport

Tipo de dados

text

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

Pathologyreport

Tipo de dados

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
Descrição

Cytogeneticsreport

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
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

PersonCompletingForm,Phone

Tipo de dados

text

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

FaxNumber

Tipo de dados

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