ID

1989

Descrizione

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

collegamento

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

Keywords

versioni (4)
  1. 19/09/12 19/09/12 -
  2. 29/07/17 29/07/17 - Martin Dugas
  3. 29/07/17 29/07/17 - Martin Dugas
  4. 20/09/21 20/09/21 -
Caricato su

19 settembre 2012

DOI

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Licenza

Creative Commons BY-NC 3.0
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Leukemia NCT00085124 Pathology - CALGB: CYTOGENETICS REFERRAL FORM - 2076684v3.0

Inglese

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 moduli  
Ccrr Module For Calgb: Cytogenetics Referral Form
Descrizione

Ccrr Module For Calgb: Cytogenetics Referral Form

CALGB Form
Descrizione

CALGBForm

Tipo di dati

text

CALGB Treatment Study #
Descrizione

CALGBTreatmentStudy#

Tipo di dati

text

CALGB Companion Study #
Descrizione

CALGBCompanionStudy#

Tipo di dati

text

CALGB Patient ID
Descrizione

CALGBPatientID

Tipo di dati

text

Amended Data?
Descrizione

AmendedDataInd

Tipo di dati

text

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

Patient'sName

Tipo di dati

text

Patient Hospital Number
Descrizione

PatientHospitalNumber

Tipo di dati

text

Main Member Institution/Adjunct
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Participating Group
Descrizione

ParticipatingGroupName

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Participating Group Patient No.
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Sex
Descrizione

PatientGender

Tipo di dati

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
Descrizione

HematopoieticDiagnosis

Tipo di dati

text

Other, specify (diagnosis)
Descrizione

other,specifyinComments(diagnosis)

Tipo di dati

text

Date sample obtained
Descrizione

Datesampleobtained

Tipo di dati

text

other, specify (sample obtained)
Descrizione

SpecimenCollectionMethod,Other

Tipo di dati

text

other, specify (reason)
Descrizione

other,specify

Tipo di dati

text

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

Lab,Hematology,WBC

Tipo di dati

double

% Blasts (blood)
Descrizione

Lab,Hematology,Blasts,CellPercentage

Tipo di dati

double

% Blasts (bone marrow)
Descrizione

BoneMarrow,Blasts,CellPercentage

Tipo di dati

double

Completed By (Print or Type Name)
Descrizione

CompletedBy

Tipo di dati

text

Date Completed
Descrizione

FormOriginalCompleteDate

Tipo di dati

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
Descrizione

PersonCompletingForm,Phone

Tipo di dati

text

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

Timesampleobtained

Tipo di dati

text

If bone marrow not submitted, give reason
Descrizione

Ifbonemarrownotsubmitted,givereason

Tipo di dati

text

Ritorna all'inizio della pagina

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 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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)
CL.1
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)
CL.2
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
CL.3
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
CL.4
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
CL.5
Code List
If bone marrow not submitted, give reason
CL Item
inaspirable (inaspirable)
CL Item
other, specify (other, specify)
Ritorna all'inizio della pagina 

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