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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

Lien

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

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
Téléchargé le

19 septembre 2012

DOI

Pour une demande vous connecter.

Licence

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

    Anglais

    No Instruction available.

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

    Unnamed1

    Registration Step
    Description

    RegistrationStep

    Type de données

    text

    Cycle Number
    Description

    CycleNumber

    Type de données

    text

    Patient?s Name
    Description

    Patient'sName

    Type de données

    text

    ECOG Protocol No.
    Description

    ECOGProtocolNo.

    Type de données

    text

    ECOG Protocol No.
    Description

    ECOGProtocolNo.

    Type de données

    text

    ECOG Patient ID
    Description

    ECOGPatientID

    Type de données

    text

    ECOG Patient ID
    Description

    ECOGPatientID

    Type de données

    text

    Participating Group Protocol No.
    Description

    ParticipatingGroupProtocolNo.

    Type de données

    text

    Participating Group Patient ID
    Description

    ParticipatingGroupPatientID

    Type de données

    text

    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Type de données

    text

    Unnamed2
    Description

    Unnamed2

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

    AmendedDataInd

    Type de données

    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

    Type de données

    date

    Marrow blasts (%)
    Description

    BoneMarrow,Blasts,CellPercentage

    Type de données

    double

    Marrow cellularity (%)
    Description

    BoneMarrow,CellularityPercentage

    Type de données

    double

    Are all cell lines maturing?
    Description

    Areallcelllinesmaturing?

    Type de données

    text

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

    BoneMarrowAuerrods

    Type de données

    text

    Is there extramedullary disease
    Description

    Isthereextramedullarydisease

    Type de données

    text

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

    ExtramedullaryDisease,OtherSite

    Type de données

    text

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

    CompleteResponseInd,Hematologic

    Type de données

    text

    Date of complete response
    Description

    CRFirstObservedDate

    Type de données

    date

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

    Comments

    Type de données

    text

    Investigator Signature
    Description

    InvestigatorSignature

    Type de données

    text

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

    InvestigatorSignatureDate

    Type de données

    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

    Type de données

    text

    Retour au début de la page

    Similar models

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    1 Formulaires
    1. StudyEvent: Acute Leukemia Disease Assessment Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    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
    Retour au début de la page 

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