ID

1989

Beschrijving

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

Trefwoorden

Versies (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 -
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19 september 2012

DOI

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

Engels

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 Formulieren  
Ccrr Module For Calgb: Cytogenetics Referral Form
Beschrijving

Ccrr Module For Calgb: Cytogenetics Referral Form

CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Treatment Study #
Beschrijving

CALGBTreatmentStudy#

Datatype

text

CALGB Companion Study #
Beschrijving

CALGBCompanionStudy#

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Amended Data?
Beschrijving

AmendedDataInd

Datatype

text

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

Patient'sName

Datatype

text

Patient Hospital Number
Beschrijving

PatientHospitalNumber

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Participating Group
Beschrijving

ParticipatingGroupName

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Sex
Beschrijving

PatientGender

Datatype

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
Beschrijving

HematopoieticDiagnosis

Datatype

text

Other, specify (diagnosis)
Beschrijving

other,specifyinComments(diagnosis)

Datatype

text

Date sample obtained
Beschrijving

Datesampleobtained

Datatype

text

other, specify (sample obtained)
Beschrijving

SpecimenCollectionMethod,Other

Datatype

text

other, specify (reason)
Beschrijving

other,specify

Datatype

text

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

Lab,Hematology,WBC

Datatype

double

% Blasts (blood)
Beschrijving

Lab,Hematology,Blasts,CellPercentage

Datatype

double

% Blasts (bone marrow)
Beschrijving

BoneMarrow,Blasts,CellPercentage

Datatype

double

Completed By (Print or Type Name)
Beschrijving

CompletedBy

Datatype

text

Date Completed
Beschrijving

FormOriginalCompleteDate

Datatype

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
Beschrijving

PersonCompletingForm,Phone

Datatype

text

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

Timesampleobtained

Datatype

text

If bone marrow not submitted, give reason
Beschrijving

Ifbonemarrownotsubmitted,givereason

Datatype

text

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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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
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