ID

24240

Description

CALGB: C-1001 NEW PRIMARY CANCER FORM Leukemia NCT00085124 Follow-Up - CALGB: C-1001 NEW PRIMARY CANCER FORM - 2076934v3.0 Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229FEB2-6C43-5155-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229FEB2-6C43-5155-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/27/17 7/27/17 - Martin Dugas
Uploaded on

July 27, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Leukemia Daunorubicin Cytarabine Oblimersen NCT00085124 CALGB

English

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms  
New Primary Cancer Form CALGB C-1001
Description

New Primary Cancer Form CALGB C-1001

Alias
UMLS CUI-1
C0751623
CALGB Form
Description

CALGB Form

Data type

text

Alias
UMLS CUI [1,1]
C1516238
UMLS CUI [1,2]
C0348078
CALGB Study No
Description

CALGB Protocol Number

Data type

text

Alias
UMLS CUI [1,1]
C1516238
UMLS CUI [1,2]
C2603343
CALGB Patient ID
Description

CALGB Patient ID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1516238
Are data amended
Description

Amended Data

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI [1,1]
C1511726
UMLS CUI [1,2]
C1691222
Patient's Name
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Patient Hospital Number
Description

Hospital Number

Data type

text

Alias
UMLS CUI [1]
C0806432
Main Member Institution/Adjunct
Description

Main Member Institution

Data type

text

Alias
UMLS CUI [1]
C1301943
Participating Group
Description

Participating Group Name

Data type

text

Alias
UMLS CUI [1]
C2347449
Participating Group Protocol No.
Description

Participating Group Protocol No

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C2347449
Participating Group Patient No.
Description

Participating Group Patient ID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
Site(s) of New Primary
Description

New Cancer Site

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25586
NCI Thesaurus Property
C25341
NCI Thesaurus ObjectClass-2
C9305
UMLS CUI [1,1]
C0751623
UMLS CUI [1,2]
C1515974
New Primary, Histologic Type
Description

Histologic Type New Primary

Data type

text

Alias
UMLS CUI [1,1]
C0449574
UMLS CUI [1,2]
C0751623
Date of Diagnosis
Description

New Cancer Diagnosis Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C9305
NCI Thesaurus Property
C15220
UMLS CUI [1,1]
C2316983
UMLS CUI [1,2]
C0751623
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1]
C0947611
Completed by (First Name. Last Name)
Description

Completed By

Data type

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Description

Form Original Complete Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1549507
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Similar models

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
New Primary Cancer Form CALGB C-1001
C0751623 (UMLS CUI-1)
CALGB Form
Item
CALGB Form
text
C1516238 (UMLS CUI [1,1])
C0348078 (UMLS CUI [1,2])
CALGB Protocol Number
Item
CALGB Study No
text
C1516238 (UMLS CUI [1,1])
C2603343 (UMLS CUI [1,2])
CALGB Patient ID
Item
CALGB Patient ID
text
C2348585 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
Amended Data
Item
Are data amended
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI [1,1])
C1691222 (UMLS CUI [1,2])
Patient Name
Item
Patient's Name
text
C1299487 (UMLS CUI [1])
Hospital Number
Item
Patient Hospital Number
text
C0806432 (UMLS CUI [1])
Main Member Institution
Item
Main Member Institution/Adjunct
text
C1301943 (UMLS CUI [1])
Participating Group Name
Item
Participating Group
text
C2347449 (UMLS CUI [1])
Participating Group Protocol No
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Participating Group Patient ID
Item
Participating Group Patient No.
text
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
New Cancer Site
Item
Site(s) of New Primary
text
C25704 (NCI Thesaurus ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C25341 (NCI Thesaurus Property)
C9305 (NCI Thesaurus ObjectClass-2)
C0751623 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Histologic Type New Primary
Item
New Primary, Histologic Type
text
C0449574 (UMLS CUI [1,1])
C0751623 (UMLS CUI [1,2])
New Cancer Diagnosis Date
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C15220 (NCI Thesaurus Property)
C2316983 (UMLS CUI [1,1])
C0751623 (UMLS CUI [1,2])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1])
Completed By
Item
Completed by (First Name. Last Name)
text
C1550483 (UMLS CUI [1])
Form Original Complete Date
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI [1])
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