ID

1993

Beschreibung

CALGB: 10201 PERIPHERAL BLOOD AND BONE MARROW REPORT 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=AD85FF2B-39F3-35D3-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AD85FF2B-39F3-35D3-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

19. September 2012

DOI

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Leukemia NCT00085124 Lab - CALGB: 10201 PERIPHERAL BLOOD AND BONE MARROW REPORT FORM - 2031273v3.0

Englisch

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

1 Formulare  
Calgb Form
Beschreibung

Calgb Form

CALGB Study No.
Beschreibung

CALGBProtocolNumber

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

From
Beschreibung

IntervalReportFromDate

Datentyp

date

To (MM DD YYYY)
Beschreibung

IntervalReportToDate

Datentyp

date

Are data Amended?
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient's Initials (Last, First, Middle)
Beschreibung

PatientInitialsName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschreibung

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientID

Datentyp

text

Current Course or Cycle No. (MM DD YYYY)
Beschreibung

CurrentCourseNumber

Datentyp

double

Bone Marrow
Beschreibung

Bone Marrow

Marrow Cellularity (0-100%)
Beschreibung

BoneMarrow,CellularityPercentage

Datentyp

double

Bone Marrow Differential
Beschreibung

Bone Marrow Differential

Marrow Promyelocytes (%)
Beschreibung

BoneMarrow,Promyelocytes,CellPercentage

Datentyp

double

Marrow Blasts (%)
Beschreibung

BoneMarrow,Blasts,CellPercentage

Datentyp

double

Marrow Lymphocytes (%)
Beschreibung

BoneMarrow,Lymphocytes,CellPercentage

Datentyp

double

Marrow Monocytes (%)
Beschreibung

MarrowMonocytes(%)

Datentyp

text

Marrow Monoblasts (%)
Beschreibung

MarrowMonoblasts(%)

Datentyp

text

Marrow Eosinophils (%)
Beschreibung

BoneMarrow,Eosinophils,CellPercentage

Datentyp

double

Marrow Basophils (%)
Beschreibung

BoneMarrow,Basophils,CellPercentage

Datentyp

double

Total Marrow Erythroid Cells (%)
Beschreibung

LaboratoryProcedureErythroidCellBoneMarrowResultPercentageValue

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C12431
UMLS 2011AA Property
C0005953
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property
C12508
UMLS 2011AA Property
C0007634
NCI Thesaurus Property
C13805
UMLS 2011AA Property
C1516960
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
Marrow Plasma Cells (%)
Beschreibung

MarrowPlasmaCells(%)

Datentyp

text

Megakaryocyte Status (MM DD YYYY)
Beschreibung

MegakaryocyteStatus

Datentyp

text

% Marrow neutrophils
Beschreibung

%Marrowneutrophils

Datentyp

text

% Marrow Metamyeocytes and Marrow Myelocytes
Beschreibung

%MarrowMetamyeocytesandMarrowMyelocytes

Datentyp

text

Peripheral Blood Differential
Beschreibung

Peripheral Blood Differential

Date Specimen Collected
Beschreibung

Lab,Hematology,SampleCollectionDate

Datentyp

date

Hemaglobin (gm/dl)
Beschreibung

Lab,Hematology,Hemoglobin

Datentyp

double

Peripheral Platelet Count (1000/ml)
Beschreibung

Lab,Hematology,Platelets

Datentyp

double

Peripheral WBC count
Beschreibung

Lab,Hematology,WBC

Datentyp

double

Peripheral neutrophils (%) (bands, segs)
Beschreibung

Lab,Hematology,Neutrophils,CellPercentage

Datentyp

double

Peripheral Metamyelocytes and Myelocytes (%)
Beschreibung

PeripheralMetamyelocytesandMyelocytes(%)

Datentyp

text

Peripheral Promyelocytes (%)
Beschreibung

Lab,Hematology,Promyelocytes,CellPercentage

Datentyp

double

Peripheral Blasts (%)
Beschreibung

Lab,Hematology,Blasts,CellPercentage

Datentyp

double

Peripheral Lymphocytes (%)
Beschreibung

Lab,Hematology,Lymphocytes,CellPercentage

Datentyp

double

Peripheral Monocytes (%)
Beschreibung

Lab,Hematology,Monocytes,CellPercentage

Datentyp

double

Peripheral Monoblasts (%)
Beschreibung

PeripheralMonoblasts(%)

Datentyp

text

Peripheral Eosinophils (%)
Beschreibung

Lab,Hematology,Eosinophils,CellPercentage

Datentyp

double

Peripheral Basophils (%)
Beschreibung

Lab,Hematology,Basophils,CellPercentage

Datentyp

double

Degree Of Dyspoiesis Present
Beschreibung

Degree Of Dyspoiesis Present

Myleopoiesis
Beschreibung

MyelopoiesisPresentRate

Datentyp

text

Alias
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C21143
UMLS 2011AA ObjectClass
C0525006
NCI Thesaurus ValueDomain
C25636
UMLS 2011AA ValueDomain
C1521828
Erythropoiesis
Beschreibung

Erythropoiesis

Datentyp

text

Megakaryopoiesis
Beschreibung

Megakaryopoiesis

Datentyp

text

Completed by (Print or Type Name)
Beschreibung

CompletedBy

Datentyp

text

Date Completed (MM DD YYYY)
Beschreibung

DateCompleted

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Calgb: 10201 Peripheral Blood And Bone Marrow Report Form
Beschreibung

Ccrr Module For Calgb: 10201 Peripheral Blood And Bone Marrow Report Form

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Ähnliche Modelle

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Calgb Form
CALGBProtocolNumber
Item
CALGB Study No.
text
CALGBPatientID
Item
CALGB Patient ID
text
IntervalReportFromDate
Item
From
date
IntervalReportToDate
Item
To (MM DD YYYY)
date
Item
Are data Amended?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data Amended?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PatientInitialsName
Item
Patient's Initials (Last, First, Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Affiliate
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
CurrentCourseNumber
Item
Current Course or Cycle No. (MM DD YYYY)
double
Item Group
Bone Marrow
BoneMarrow,CellularityPercentage
Item
Marrow Cellularity (0-100%)
double
Item Group
Bone Marrow Differential
BoneMarrow,Promyelocytes,CellPercentage
Item
Marrow Promyelocytes (%)
double
BoneMarrow,Blasts,CellPercentage
Item
Marrow Blasts (%)
double
BoneMarrow,Lymphocytes,CellPercentage
Item
Marrow Lymphocytes (%)
double
MarrowMonocytes(%)
Item
Marrow Monocytes (%)
text
MarrowMonoblasts(%)
Item
Marrow Monoblasts (%)
text
BoneMarrow,Eosinophils,CellPercentage
Item
Marrow Eosinophils (%)
double
BoneMarrow,Basophils,CellPercentage
Item
Marrow Basophils (%)
double
LaboratoryProcedureErythroidCellBoneMarrowResultPercentageValue
Item
Total Marrow Erythroid Cells (%)
double
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C12431 (NCI Thesaurus Property)
C0005953 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C13805 (NCI Thesaurus Property)
C1516960 (UMLS 2011AA Property)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
MarrowPlasmaCells(%)
Item
Marrow Plasma Cells (%)
text
Item
Megakaryocyte Status (MM DD YYYY)
text
CL.2
Code List
Megakaryocyte Status (MM DD YYYY)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Decreased (Decreased)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Increased (Increased)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
%Marrowneutrophils
Item
% Marrow neutrophils
text
%MarrowMetamyeocytesandMarrowMyelocytes
Item
% Marrow Metamyeocytes and Marrow Myelocytes
text
Item Group
Peripheral Blood Differential
Lab,Hematology,SampleCollectionDate
Item
Date Specimen Collected
date
Lab,Hematology,Hemoglobin
Item
Hemaglobin (gm/dl)
double
Lab,Hematology,Platelets
Item
Peripheral Platelet Count (1000/ml)
double
Lab,Hematology,WBC
Item
Peripheral WBC count
double
Lab,Hematology,Neutrophils,CellPercentage
Item
Peripheral neutrophils (%) (bands, segs)
double
PeripheralMetamyelocytesandMyelocytes(%)
Item
Peripheral Metamyelocytes and Myelocytes (%)
text
Lab,Hematology,Promyelocytes,CellPercentage
Item
Peripheral Promyelocytes (%)
double
Lab,Hematology,Blasts,CellPercentage
Item
Peripheral Blasts (%)
double
Lab,Hematology,Lymphocytes,CellPercentage
Item
Peripheral Lymphocytes (%)
double
Lab,Hematology,Monocytes,CellPercentage
Item
Peripheral Monocytes (%)
double
PeripheralMonoblasts(%)
Item
Peripheral Monoblasts (%)
text
Lab,Hematology,Eosinophils,CellPercentage
Item
Peripheral Eosinophils (%)
double
Lab,Hematology,Basophils,CellPercentage
Item
Peripheral Basophils (%)
double
Item Group
Degree Of Dyspoiesis Present
Item
Myleopoiesis
text
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C21143 (NCI Thesaurus ObjectClass)
C0525006 (UMLS 2011AA ObjectClass)
C25636 (NCI Thesaurus ValueDomain)
C1521828 (UMLS 2011AA ValueDomain)
CL.3
Code List
Myleopoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
Item
Erythropoiesis
text
CL.4
Code List
Erythropoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
Item
Megakaryopoiesis
text
CL.5
Code List
Megakaryopoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
CompletedBy
Item
Completed by (Print or Type Name)
text
DateCompleted
Item
Date Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Calgb: 10201 Peripheral Blood And Bone Marrow Report Form
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