ID

1989

Description

CALGB: CYTOGENETICS REFERRAL 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=B229EF62-6ADF-5120-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229EF62-6ADF-5120-E034-0003BA12F5E7

Keywords

  1. 9/19/12 9/19/12 -
  2. 7/29/17 7/29/17 - Martin Dugas
  3. 7/29/17 7/29/17 - Martin Dugas
  4. 9/20/21 9/20/21 -
Uploaded on

September 19, 2012

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Leukemia NCT00085124 Pathology - CALGB: CYTOGENETICS REFERRAL FORM - 2076684v3.0

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: Cytogenetics Referral Form
Description

Ccrr Module For Calgb: Cytogenetics Referral Form

CALGB Form
Description

CALGBForm

Data type

text

CALGB Treatment Study #
Description

CALGBTreatmentStudy#

Data type

text

CALGB Companion Study #
Description

CALGBCompanionStudy#

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended Data?
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
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

Sex
Description

PatientGender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17357
UMLS 2011AA Property
C0079399
Diagnosis
Description

HematopoieticDiagnosis

Data type

text

Other, specify (diagnosis)
Description

other,specifyinComments(diagnosis)

Data type

text

Date sample obtained
Description

Datesampleobtained

Data type

text

other, specify (sample obtained)
Description

SpecimenCollectionMethod,Other

Data type

text

other, specify (reason)
Description

other,specify

Data type

text

Alias
NCI Thesaurus ObjectClass
C25179
UMLS 2011AA ObjectClass
C0019993
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
WBC (blood)
Description

Lab,Hematology,WBC

Data type

double

% Blasts (blood)
Description

Lab,Hematology,Blasts,CellPercentage

Data type

double

% Blasts (bone marrow)
Description

BoneMarrow,Blasts,CellPercentage

Data type

double

Completed By (Print or Type Name)
Description

CompletedBy

Data type

text

Date Completed
Description

FormOriginalCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
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
C25367
Telephone Number
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Time sample obtained
Description

Timesampleobtained

Data type

text

If bone marrow not submitted, give reason
Description

Ifbonemarrownotsubmitted,givereason

Data type

text

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
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb: Cytogenetics Referral Form
CALGBForm
Item
CALGB Form
text
CALGBTreatmentStudy#
Item
CALGB Treatment Study #
text
CALGBCompanionStudy#
Item
CALGB Companion Study #
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended Data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Code List
Amended Data?
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
Item
Sex
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
Code List
Sex
CL Item
Male (male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (female)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
Item
Diagnosis
text
Code List
Diagnosis
CL Item
ALL (ALL)
CL Item
AML (AML)
CL Item
MDS (MDS)
CL Item
CML (CML)
CL Item
Other, specify (Other, specify)
other,specifyinComments(diagnosis)
Item
Other, specify (diagnosis)
text
Datesampleobtained
Item
Date sample obtained
text
SpecimenCollectionMethod,Other
Item
other, specify (sample obtained)
text
other,specify
Item
other, specify (reason)
text
C25179 (NCI Thesaurus ObjectClass)
C0019993 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Lab,Hematology,WBC
Item
WBC (blood)
double
Lab,Hematology,Blasts,CellPercentage
Item
% Blasts (blood)
double
BoneMarrow,Blasts,CellPercentage
Item
% Blasts (bone marrow)
double
CompletedBy
Item
Completed By (Print or Type Name)
text
FormOriginalCompleteDate
Item
Date Completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
PersonCompletingForm,Phone
Item
Telephone Number
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Time sample obtained
text
Code List
Time sample obtained
CL Item
sample obtained (sample obtained)
CL Item
bone marrow aspirate (bone marrow aspirate)
CL Item
blood (blood)
CL Item
other, specify (other, specify)
Item
If bone marrow not submitted, give reason
text
Code List
If bone marrow not submitted, give reason
CL Item
inaspirable (inaspirable)
CL Item
other, specify (other, specify)

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

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