ID

2054

Description

SOUTHWEST ONCOLOGY GROUP LEUKEMIA RESPONSE FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB44CFF-75C7-4219-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB44CFF-75C7-4219-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/20/17 8/20/17 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Response - SOUTHWEST ONCOLOGY GROUP LEUKEMIA RESPONSE FORM - 2070922v3.0

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  
Response
Description

Response

Has the patient had a documented clinical assessment for this cancer?
Description

CancerFollow-upStatusInd

Data type

text

Date of Last Clinical Assessment (only provide date if assessment during this reporting period)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
Description

CompleteResponseInd,Hematologic

Data type

text

Date of Complete Response (only provide date if CR was achieved during this reporting period)
Description

CRFirstObservedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
UMLS 2011AA ObjectClass
C0871261
NCI Thesaurus Property
C15722
UMLS 2011AA Property
C0700325
Laboratory Values And Extramedullary Disease Involvement
Description

Laboratory Values And Extramedullary Disease Involvement

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

Date of Examination for Extramedullary Disease
Description

PatientExtramedullaryDiseaseAssessmentDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C2991
UMLS 2011AA Property
C0012634
NCI Thesaurus Property
C25503
UMLS 2011AA Property
C1517060
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Extramedullary Disease Involvement: (check all that apply)
Description

ExtramedullaryDisease

Data type

text

Other, specify (extramedullary disease)
Description

ExtramedullaryDisease,OtherSite

Data type

text

Did the patient receive a lumbar puncture during this reporting period? (If yes,)
Description

Didthepatientreceivealumbarpunctureduringthisreportingperiod?

Data type

text

date of Lumbar Puncture
Description

dateofLumbarPuncture

Data type

text

CNS Disease
Description

CNSSiteInd

Data type

text

Notes
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group Leukemia Response Form
Description

Ccrr Module For Southwest Oncology Group Leukemia Response 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
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
Cycle
Description

TreatmentPhase

Data type

text

Reporting Period Start Date
Description

IntervalReportFromDate

Data type

date

Reporting Period End Date
Description

IntervalReportToDate

Data type

date

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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
Response
Item
Has the patient had a documented clinical assessment for this cancer?
text
CL.1
Code List
Has the patient had a documented clinical assessment for this cancer?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of Last Clinical Assessment (only provide date if assessment during this reporting period)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
text
CL.2
Code List
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
CL Item
Null (Yes)
CL Item
Null (No)
CL Item
Null (Unknown)
CRFirstObservedDate
Item
Date of Complete Response (only provide date if CR was achieved during this reporting period)
date
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C15722 (NCI Thesaurus Property)
C0700325 (UMLS 2011AA Property)
Item Group
Laboratory Values And Extramedullary Disease Involvement
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.3
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)
PatientExtramedullaryDiseaseAssessmentDate
Item
Date of Examination for Extramedullary Disease
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C25503 (NCI Thesaurus Property)
C1517060 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Extramedullary Disease Involvement: (check all that apply)
text
CL.4
Code List
Extramedullary Disease Involvement: (check all that apply)
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 (leukemia cutis))
CL Item
Other Specified Extramedullary Disease Present (Other,)
ExtramedullaryDisease,OtherSite
Item
Other, specify (extramedullary disease)
text
Item
Did the patient receive a lumbar puncture during this reporting period? (If yes,)
text
CL.5
Code List
Did the patient receive a lumbar puncture during this reporting period? (If yes,)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
dateofLumbarPuncture
Item
date of Lumbar Puncture
text
Item
CNS Disease
text
CL.6
Code List
CNS Disease
CL Item
Present (Present)
CL Item
No (Absent)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Indeterminate)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Comments
Item
Notes
text
Item Group
Ccrr Module For Southwest Oncology Group Leukemia Response 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)
Item
Cycle
text
CL.7
Code List
Cycle
CL Item
Current Phase Of Leukemia Treatment For Patient Is Induction (First Induction)
CL Item
Cross-over Induction (Cross-over Induction)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Consolidation (Consolidation)
IntervalReportFromDate
Item
Reporting Period Start Date
date
IntervalReportToDate
Item
Reporting Period End Date
date
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