ID

2054

Beschreibung

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

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 20.08.17 20.08.17 -
Hochgeladen am

19. September 2012

DOI

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Lizenz

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

Englisch

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 Formulare  
Response
Beschreibung

Response

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

CancerFollow-upStatusInd

Datentyp

text

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

CancerFollow-upStatusDate

Datentyp

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?
Beschreibung

CompleteResponseInd,Hematologic

Datentyp

text

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

CRFirstObservedDate

Datentyp

date

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

Laboratory Values And Extramedullary Disease Involvement

Date of Blood Values
Beschreibung

Lab,Hematology,SampleCollectionDate

Datentyp

date

HGB (g%)
Beschreibung

Lab,Hematology,Hemoglobin

Datentyp

double

PLTS (x10 : 3)
Beschreibung

Lab,Hematology,Platelets

Datentyp

double

WBC (x10 : 3)
Beschreibung

Lab,Hematology,WBC

Datentyp

double

Peripheral Blasts (%)
Beschreibung

Lab,Hematology,Blasts,CellPercentage

Datentyp

double

Peripheral Neutrophils (%)
Beschreibung

Lab,Hematology,Neutrophils,CellPercentage

Datentyp

double

Peripheral Lymphocytes (%)
Beschreibung

Lab,Hematology,Lymphocytes,CellPercentage

Datentyp

double

Peripheral Monocytes (%)
Beschreibung

Lab,Hematology,Monocytes,CellPercentage

Datentyp

double

Date of Bone Marrow Biopsy/Aspiration
Beschreibung

BoneMarrowBiopsyDate

Datentyp

date

Marrow Cellularity (%)
Beschreibung

BoneMarrow,CellularityPercentage

Datentyp

double

Marrow Blasts (%)
Beschreibung

BoneMarrow,Blasts,CellPercentage

Datentyp

double

Marrow Lymphocytes (%)
Beschreibung

BoneMarrow,Lymphocytes,CellPercentage

Datentyp

double

Cellularity Status (select one:)
Beschreibung

BoneMarrow,CellularityStatus

Datentyp

text

Date of Examination for Extramedullary Disease
Beschreibung

PatientExtramedullaryDiseaseAssessmentDate

Datentyp

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)
Beschreibung

ExtramedullaryDisease

Datentyp

text

Other, specify (extramedullary disease)
Beschreibung

ExtramedullaryDisease,OtherSite

Datentyp

text

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

Didthepatientreceivealumbarpunctureduringthisreportingperiod?

Datentyp

text

date of Lumbar Puncture
Beschreibung

dateofLumbarPuncture

Datentyp

text

CNS Disease
Beschreibung

CNSSiteInd

Datentyp

text

Notes
Beschreibung

Comments

Datentyp

text

Ccrr Module For Southwest Oncology Group Leukemia Response Form
Beschreibung

Ccrr Module For Southwest Oncology Group Leukemia Response Form

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F, M)
Beschreibung

PatientInitials

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Physician
Beschreibung

TreatingPhysician

Datentyp

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
Beschreibung

TreatmentPhase

Datentyp

text

Reporting Period Start Date
Beschreibung

IntervalReportFromDate

Datentyp

date

Reporting Period End Date
Beschreibung

IntervalReportToDate

Datentyp

date

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Ähnliche Modelle

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 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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