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Informations:
Erreur:
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
Lien
Mots-clés
Versions (4)
- 19/09/2012 19/09/2012 -
- 29/07/2017 29/07/2017 - Martin Dugas
- 29/07/2017 29/07/2017 - Martin Dugas
- 20/09/2021 20/09/2021 -
Téléchargé le
19 septembre 2012
DOI
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Licence
Creative Commons BY-NC 3.0
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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.
- StudyEvent: CALGB: CYTOGENETICS REFERRAL FORM
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.
- StudyEvent: CALGB: CYTOGENETICS REFERRAL FORM
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
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)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
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)
C0683312 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS 2011AA Property)
CL Item
Male (male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
C1706180 (UMLS 2011AA)
CL Item
Female (female)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
C0015780 (UMLS 2011AA)
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)
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)
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)
C1527021 (UMLS 2011AA ValueDomain)
CL Item
sample obtained (sample obtained)
CL Item
bone marrow aspirate (bone marrow aspirate)
CL Item
blood (blood)
CL Item
other, specify (other, specify)
CL Item
inaspirable (inaspirable)
CL Item
other, specify (other, specify)