ID

24307

Description

CALGB: C-215 Secondary Form NCT00085124 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=B229FC8D-B88E-5150-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229FC8D-B88E-5150-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 7/29/17 7/29/17 - Martin Dugas
  3. 7/29/17 7/29/17 - Martin Dugas
Uploaded on

July 29, 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  
CALGB C-215 Secondary Form
Description

CALGB C-215 Secondary Form

Alias
UMLS CUI-1
C1320722
CALGB Form
Description

CALGB Form

Data type

text

Alias
UMLS CUI-1
C3262252
UMLS CUI-2
C1516238
CALGB Study No
Description

CALGBProtocolNumber

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1516238
CALGB Patient ID
Description

CALGBPatientID

Data type

text

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

Data amended

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'sName

Data type

text

Alias
UMLS CUI [1]
C1299487
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Alias
UMLS CUI [1]
C0421459
Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Data type

text

Alias
UMLS CUI [1]
C1301943
Participating Group
Description

ParticipatingGroupName

Data type

text

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

ParticipatingGroupProtocolNo.

Data type

text

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

ParticipatingGroupPatientID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
Date of diagnosis of secondary AML/MDS
Description

Second Primary Tumor Diagnosis Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C3262
NCI Thesaurus ObjectClass-2
C25251
NCI Thesaurus ObjectClass-3
C25666
NCI Thesaurus Property
C15220
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C0751623
UMLS CUI [1,2]
C2316983
Has the NCI/CTEP secondary AML/MDS report form been sent to the CALGB central office?
Description

HastheNCI/CTEPsecondaryAML/MDSreportformbeensenttotheCALGBcentraloffice?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI [1]
C0684224
Explain why the form was not sent
Description

Explainwhytheformwasnotsent

Data type

text

Alias
UMLS CUI [1]
C0814891
Date the form was sent
Description

Datetheformwassent

Data type

date

Alias
UMLS CUI [1,1]
C1515022
UMLS CUI [1,2]
C0011008
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
Description

CompletedBy (First Name. Last Name)

Data type

text

Alias
UMLS CUI [1]
C1550483
Date Form Completed
Description

Form Completion Date (Y Y Y Y D D M M)

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
CALGB C-215 Secondary Form
C1320722 (UMLS CUI-1)
CALGB Form
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGB Study No
Item
CALGB Study No
text
C3274381 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
CALGB Patient ID
Item
CALGB Patient ID
text
C2348585 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
data amended
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])
Patient Hospital Number
Item
Patient Hospital Number
text
C0421459 (UMLS CUI [1])
Main Member Institution
Item
Main Member Institution/Adjunct
text
C1301943 (UMLS CUI [1])
Participating Group
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 Number
Item
Participating Group Patient No.
text
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Second Primary Tumor Diagnosis Date
Item
Date of diagnosis of secondary AML/MDS
date
C3262 (NCI Thesaurus ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C15220 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0751623 (UMLS CUI [1,1])
C2316983 (UMLS CUI [1,2])
Report sent
Item
Has the NCI/CTEP secondary AML/MDS report form been sent to the CALGB central office?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0684224 (UMLS CUI [1])
missing form reason
Item
Explain why the form was not sent
text
C0814891 (UMLS CUI [1])
Submission date
Item
Date the form was sent
date
C1515022 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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
text
C1550483 (UMLS CUI [1])
Date Form Completed
Item
Date Form 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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