ID

2335

Description

Acute Leukemia Disease Assessment Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727ECDC-BAED-2F88-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727ECDC-BAED-2F88-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00049517 Response - Acute Leukemia Disease Assessment Form - 2053949v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Acute Leukemia Disease Assessment Form
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Registration Step
Description

RegistrationStep

Data type

text

Cycle Number
Description

CycleNumber

Data type

text

Patient?s Name
Description

Patient'sName

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Unnamed2
Description

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Date of bone marrow biopsy
Description

BoneMarrowBiopsyDate

Data type

date

Marrow blasts (%)
Description

BoneMarrow,Blasts,CellPercentage

Data type

double

Marrow cellularity (%)
Description

BoneMarrow,CellularityPercentage

Data type

double

Are all cell lines maturing?
Description

Areallcelllinesmaturing?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Are auer rods present?
Description

BoneMarrowAuerrods

Data type

text

Is there extramedullary disease
Description

Isthereextramedullarydisease

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
yes, specify sites (extramedullary disease)
Description

ExtramedullaryDisease,OtherSite

Data type

text

Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
Description

CompleteResponseInd,Hematologic

Data type

text

Date of complete response
Description

CRFirstObservedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
UMLS 2011AA ObjectClass
C0871261
NCI Thesaurus Property
C15722
UMLS 2011AA Property
C0700325
Comments
Description

Comments

Data type

text

Investigator Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For Acute Leukemia Disease Assessment Form
Description

Ccrr Module For Acute Leukemia Disease Assessment Form

specify sites of extramedullary disease
Description

specifysitesofextramedullarydisease

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Acute Leukemia Disease Assessment Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
CycleNumber
Item
Cycle Number
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
BoneMarrowBiopsyDate
Item
Date of bone marrow biopsy
date
BoneMarrow,Blasts,CellPercentage
Item
Marrow blasts (%)
double
BoneMarrow,CellularityPercentage
Item
Marrow cellularity (%)
double
Item
Are all cell lines maturing?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.2
Code List
Are all cell lines maturing?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Are auer rods present?
text
CL.3
Code List
Are auer rods present?
CL Item
Auer Rods Absent From Bone Marrow (absent)
CL Item
Auer Rods Present In Bone Marrow (present)
Item
Is there extramedullary disease
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
Is there extramedullary disease
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ExtramedullaryDisease,OtherSite
Item
yes, specify sites (extramedullary disease)
text
Item
Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
text
CL.5
Code List
Did the patient achieve a complete response according to clinical/hematologic criteria during this reporting period?
CL Item
Null (no)
CL Item
Null (yes)
CL Item
Null (unknown)
CRFirstObservedDate
Item
Date of complete response
date
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C15722 (NCI Thesaurus Property)
C0700325 (UMLS 2011AA Property)
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Acute Leukemia Disease Assessment Form
specifysitesofextramedullarydisease
Item
specify sites of extramedullary disease
text
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