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2043

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S0100 PREVIOUSLY UNTREATED ACUTE LYMPHOBLASTIC LEUKEMIA PRESTUDY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 8/2/17 8/2/17 - Martin Dugas
  3. 8/2/17 8/2/17 - Martin Dugas
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September 19, 2012

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Creative Commons BY-NC 3.0 Legacy
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    Leukemia null On-Study - S0100 PREVIOUSLY UNTREATED ACUTE LYMPHOBLASTIC LEUKEMIA PRESTUDY FORM - 2070619v3.0

    English

    Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

    1 forms  
    Patient And Disease Description
    Description

    Patient And Disease Description

    Zubrod performance status
    Description

    PerformanceStatus

    Data type

    text

    Height (cm:)
    Description

    PatientHeight

    Data type

    double

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25347 (undefined)
    UMLS 2011AA Property
    C0489786 (Height)
    LOINC
    LP72681-7
    Date of First Pathologic Diagnosis
    Description

    InitialDiagnosisDate

    Data type

    date

    FAB Classification (select one:)
    Description

    Leukemia/MDSClassification

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372 (undefined)
    UMLS 2011AA ValueDomain
    C0683312 (Categories)
    LOINC
    MTHU018876
    NCI Thesaurus ObjectClass
    C3161 (undefined)
    UMLS 2011AA ObjectClass
    C0023418 (leukemia)
    SNOMED
    93143009
    NCI Thesaurus Property
    C25161 (undefined)
    UMLS 2011AA Property
    C0008902 (Classification)
    SNOMED
    73504009
    Extramedullary Disease Involvement (check all that apply)
    Description

    ExtramedullaryDisease

    Data type

    text

    Other specify (extramedullary disease inv)
    Description

    ExtramedullaryDisease,OtherSite

    Data type

    text

    Organ Involvement
    Description

    Organ Involvement

    Palpable Splenomegaly?
    Description

    Splenomegaly,Palpation

    Data type

    text

    Alias
    NCI Thesaurus Property
    C16950 (undefined)
    UMLS 2011AA Property
    C0030247 (Palpation)
    SNOMED
    113011001
    LOINC
    LP6435-4
    NCI Thesaurus ObjectClass
    C3384 (undefined)
    UMLS 2011AA ObjectClass
    C0038002 (Splenomegaly)
    SNOMED
    16294009
    Splenomegaly by scan or x-ray?
    Description

    Splenomegaly,Imaging

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3384 (undefined)
    UMLS 2011AA ObjectClass
    C0038002 (Splenomegaly)
    SNOMED
    16294009
    NCI Thesaurus Property
    C19477 (undefined)
    UMLS 2011AA Property
    C1704254 (Medical Image)
    Palpable Hepatomegaly?
    Description

    Hepatomegaly,Palpation

    Data type

    text

    Alias
    NCI Thesaurus Property
    C16950 (undefined)
    UMLS 2011AA Property
    C0030247 (Palpation)
    SNOMED
    113011001
    LOINC
    LP6435-4
    NCI Thesaurus ObjectClass
    C3100 (undefined)
    UMLS 2011AA ObjectClass
    C0017924 (Glycogen Storage Disease Type V)
    SNOMED
    55912009
    Hepatomegaly by scan or x-ray?
    Description

    Hepatomegaly,Imaging

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3100 (undefined)
    UMLS 2011AA ObjectClass
    C0017924 (Glycogen Storage Disease Type V)
    SNOMED
    55912009
    NCI Thesaurus Property
    C19477 (undefined)
    UMLS 2011AA Property
    C1704254 (Medical Image)
    Palpable Lymphadenopathy?
    Description

    Lymphadenopathy,Palpation

    Data type

    text

    Alias
    NCI Thesaurus Property
    C16950 (undefined)
    UMLS 2011AA Property
    C0030247 (Palpation)
    SNOMED
    113011001
    LOINC
    LP6435-4
    NCI Thesaurus ObjectClass
    C3206 (undefined)
    UMLS 2011AA ObjectClass
    C0024228 (Lymphatic Diseases)
    SNOMED
    3305006
    Lymphadenopathy by scan or x-ray?
    Description

    Lymphadenopathy,Imaging

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C3206 (undefined)
    UMLS 2011AA ObjectClass
    C0024228 (Lymphatic Diseases)
    SNOMED
    3305006
    NCI Thesaurus Property
    C19477 (undefined)
    UMLS 2011AA Property
    C1704254 (Medical Image)
    Immunophenotype
    Description

    Immunophenotype

    Data type

    text

    Other, specify (immunophenotype)
    Description

    Immunophenotype,Other

    Data type

    text

    Current Laboratory Values
    Description

    Current Laboratory Values

    Date of Blood Values
    Description

    Lab,Hematology,SampleCollectionDate

    Data type

    date

    HGB (g%)
    Description

    Lab,Hematology,Hemoglobin

    Data type

    double

    PLTS (x10 : 3)
    Description

    Lab,Hematology,Platelets

    Data type

    double

    WBC (x10 : 3)
    Description

    Lab,Hematology,WBC

    Data type

    double

    Peripheral Blasts (%)
    Description

    Lab,Hematology,Blasts,CellPercentage

    Data type

    double

    Peripheral Neutrophils (%)
    Description

    Lab,Hematology,Neutrophils,CellPercentage

    Data type

    double

    Peripheral Lymphocytes (%)
    Description

    Lab,Hematology,Lymphocytes,CellPercentage

    Data type

    double

    Peripheral Monocytes (%)
    Description

    Lab,Hematology,Monocytes,CellPercentage

    Data type

    double

    Date of Bone Marrow Biopsy/Aspiration
    Description

    BoneMarrowBiopsyDate

    Data type

    date

    Marrow Cellularity (%)
    Description

    BoneMarrow,CellularityPercentage

    Data type

    double

    Marrow Blasts (%)
    Description

    BoneMarrow,Blasts,CellPercentage

    Data type

    double

    Marrow Lymphocytes (%)
    Description

    BoneMarrow,Lymphocytes,CellPercentage

    Data type

    double

    Cellularity Status (select one:)
    Description

    BoneMarrow,CellularityStatus

    Data type

    text

    Comments
    Description

    Comments

    Data type

    text

    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
    Description

    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form

    SWOG Patient ID
    Description

    SWOGPatientID

    Data type

    text

    SWOG Study No.
    Description

    SWOGStudyNo.

    Data type

    text

    Registration Step
    Description

    RegistrationStep

    Data type

    text

    Patient Initials (L, F, M)
    Description

    PatientInitials

    Data type

    text

    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Data type

    text

    Physician
    Description

    TreatingPhysician

    Data type

    text

    Alias
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25741 (undefined)
    UMLS 2011AA ObjectClass
    C0031831 (Physicians)
    SNOMED
    158965000
    LOINC
    LA18968-0
    NCI Thesaurus ObjectClass
    C25705 (undefined)
    UMLS 2011AA ObjectClass
    C1522326 (Treating)
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    Similar models

    Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient And Disease Description
    PerformanceStatus
    Item
    Zubrod performance status
    text
    PatientHeight
    Item
    Height (cm:)
    double
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS 2011AA Property)
    InitialDiagnosisDate
    Item
    Date of First Pathologic Diagnosis
    date
    Item
    FAB Classification (select one:)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C25161 (NCI Thesaurus Property)
    C0008902 (UMLS 2011AA Property)
    CL.1
    Code List
    FAB Classification (select one:)
    CL Item
    Disease Classified As Acute Lympoblastic Leukemia (fab L1) (L1)
    CL Item
    Disease Classified As Acute Lymphoblastic Leukemia (fab L2) (L2)
    CL Item
    Disease Is A Mixed Lineage Acute Leukemia (Mixed lineage ALL)
    Item
    Extramedullary Disease Involvement (check all that apply)
    text
    CL.2
    Code List
    Extramedullary Disease Involvement (check all that apply)
    CL Item
    Pathology Or Disease Involving The Central Nervous System Present (Central Nervous System)
    CL Item
    Pathology Or Disease Involving The Peripheral Nervous System Present (Peripheral Nervous System)
    CL Item
    Gingival Hypertrophy Present (Gingival Hypertrophy)
    CL Item
    Mediastinal Mass Present (Mediastinal Mass)
    CL Item
    Pathology Or Disease Involving The Skin Present (Skin)
    CL Item
    Other Specified Extramedullary Disease Present (Other, specify)
    ExtramedullaryDisease,OtherSite
    Item
    Other specify (extramedullary disease inv)
    text
    Item Group
    Organ Involvement
    Item
    Palpable Splenomegaly?
    text
    C16950 (NCI Thesaurus Property)
    C0030247 (UMLS 2011AA Property)
    C3384 (NCI Thesaurus ObjectClass)
    C0038002 (UMLS 2011AA ObjectClass)
    CL.3
    Code List
    Palpable Splenomegaly?
    CL Item
    Palpation Performed And Splenomegaly Present (Yes)
    CL Item
    Palpation Performed And Splenomegaly Absent (No)
    CL Item
    Palpation Of Spleen Not Performed (Not examined)
    CL Item
    Surgically absent (Surgically absent)
    Item
    Splenomegaly by scan or x-ray?
    text
    C3384 (NCI Thesaurus ObjectClass)
    C0038002 (UMLS 2011AA ObjectClass)
    C19477 (NCI Thesaurus Property)
    C1704254 (UMLS 2011AA Property)
    CL.4
    Code List
    Splenomegaly by scan or x-ray?
    CL Item
    Imaging Performed And Splenomegaly Present (Yes)
    CL Item
    Imaging Performed And Splenomegaly Absent (No)
    CL Item
    Imaging Of Spleen Not Performed (Not examined)
    CL Item
    Spleen Removed Via Prior Surgery (Surgically absent)
    Item
    Palpable Hepatomegaly?
    text
    C16950 (NCI Thesaurus Property)
    C0030247 (UMLS 2011AA Property)
    C3100 (NCI Thesaurus ObjectClass)
    C0017924 (UMLS 2011AA ObjectClass)
    CL.5
    Code List
    Palpable Hepatomegaly?
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    CL Item
    Not examined (Not examined)
    Item
    Hepatomegaly by scan or x-ray?
    text
    C3100 (NCI Thesaurus ObjectClass)
    C0017924 (UMLS 2011AA ObjectClass)
    C19477 (NCI Thesaurus Property)
    C1704254 (UMLS 2011AA Property)
    CL.6
    Code List
    Hepatomegaly by scan or x-ray?
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    CL Item
    Not examined (Not examined)
    Item
    Palpable Lymphadenopathy?
    text
    C16950 (NCI Thesaurus Property)
    C0030247 (UMLS 2011AA Property)
    C3206 (NCI Thesaurus ObjectClass)
    C0024228 (UMLS 2011AA ObjectClass)
    CL.7
    Code List
    Palpable Lymphadenopathy?
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    Item
    Lymphadenopathy by scan or x-ray?
    text
    C3206 (NCI Thesaurus ObjectClass)
    C0024228 (UMLS 2011AA ObjectClass)
    C19477 (NCI Thesaurus Property)
    C1704254 (UMLS 2011AA Property)
    CL.8
    Code List
    Lymphadenopathy by scan or x-ray?
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    CL Item
    Not examined (Not examined)
    Item
    Immunophenotype
    text
    CL.9
    Code List
    Immunophenotype
    CL Item
    T-cell Immunophenotype (T-cell)
    CL Item
    pre B-cell (pre B-cell)
    CL Item
    B-cell Immunophenotype (B-cell)
    CL Item
    Unknown (Unknown)
    CL Item
    Other Specified Immunophenotype (Other, specify)
    CL Item
    Indeterminate Immunophenotype (Indeterminate)
    CL Item
    Mixed Cells Immunophenotype (Mixed)
    CL Item
    Non-t/non-b Cell Immunophenotype (Non-T/Non-B)
    Immunophenotype,Other
    Item
    Other, specify (immunophenotype)
    text
    Item Group
    Current Laboratory Values
    Lab,Hematology,SampleCollectionDate
    Item
    Date of Blood Values
    date
    Lab,Hematology,Hemoglobin
    Item
    HGB (g%)
    double
    Lab,Hematology,Platelets
    Item
    PLTS (x10 : 3)
    double
    Lab,Hematology,WBC
    Item
    WBC (x10 : 3)
    double
    Lab,Hematology,Blasts,CellPercentage
    Item
    Peripheral Blasts (%)
    double
    Lab,Hematology,Neutrophils,CellPercentage
    Item
    Peripheral Neutrophils (%)
    double
    Lab,Hematology,Lymphocytes,CellPercentage
    Item
    Peripheral Lymphocytes (%)
    double
    Lab,Hematology,Monocytes,CellPercentage
    Item
    Peripheral Monocytes (%)
    double
    BoneMarrowBiopsyDate
    Item
    Date of Bone Marrow Biopsy/Aspiration
    date
    BoneMarrow,CellularityPercentage
    Item
    Marrow Cellularity (%)
    double
    BoneMarrow,Blasts,CellPercentage
    Item
    Marrow Blasts (%)
    double
    BoneMarrow,Lymphocytes,CellPercentage
    Item
    Marrow Lymphocytes (%)
    double
    Item
    Cellularity Status (select one:)
    text
    CL.10
    Code List
    Cellularity Status (select one:)
    CL Item
    Cellularity Status Of Bone Marrow Is Aplasitc (severely Hypocellular) (Aplastic)
    CL Item
    Cellularity Status Of Bone Marrow Is Hypocellular (Hypocellular)
    CL Item
    Cellularity Status Of Bone Marrow Is Normocellular (Normocellular)
    CL Item
    Cellularity Status Of Bone Marrow Is Hypercellular (Hypercellular)
    CL Item
    Cellularity Status Of Bone Marrow Is Packed (intensely Hypercellular) (Packed)
    CL Item
    Cellularity Status Of Bone Marrow Unknown, Procedure Resulted In No Material To Analyze (Dry tap or inaspirable)
    Comments
    Item
    Comments
    text
    Item Group
    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    PatientInitials
    Item
    Patient Initials (L, F, M)
    text
    MainMemberInstitution/Affiliate
    Item
    Institution/Affiliate
    text
    TreatingPhysician
    Item
    Physician
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25741 (NCI Thesaurus ObjectClass)
    C0031831 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass)
    C1522326 (UMLS 2011AA ObjectClass)
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