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24486

Beskrivning

S0100 PREVIOUSLY UNTREATED ACUTE LYMPHOBLASTIC LEUKEMIA PRESTUDY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2017-08-02 2017-08-02 - Martin Dugas
  3. 2017-08-02 2017-08-02 - Martin Dugas
Uppladdad den

2 augusti 2017

DOI

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Licens

Creative Commons BY-NC 3.0
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    PRESTUDY FORM

    Engelsk

    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 Formulär  
    Patient And Disease Description
    Beskrivning

    Patient And Disease Description

    Alias
    UMLS CUI-1
    C3259023
    Zubrod performance status
    Beskrivning

    Performance Status

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C3714786
    Height
    Beskrivning

    Patient Height

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25347
    UMLS CUI [1]
    C0489786
    Date of First Pathologic Diagnosis
    Beskrivning

    Initial Diagnosis Date

    Datatyp

    date

    Alias
    UMLS CUI [1]
    C2316983
    FAB Classification
    Beskrivning

    Leukemia/MDS Classification

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    NCI Thesaurus ObjectClass
    C3161
    NCI Thesaurus Property
    C25161
    UMLS CUI [1]
    C2984084
    Extramedullary Disease Involvement
    Beskrivning

    Extramedullary Disease

    Datatyp

    text

    Alias
    UMLS CUI [1,1]
    C1517060
    UMLS CUI [1,2]
    C0012634
    Other specify
    Beskrivning

    Extramedullary Disease, other

    Datatyp

    text

    Alias
    UMLS CUI [1,1]
    C1517060
    UMLS CUI [1,2]
    C0012634
    Organ Involvement
    Beskrivning

    Organ Involvement

    Alias
    UMLS CUI-1
    C0457577
    Palpable Splenomegaly?
    Beskrivning

    Splenomegaly, Palpation

    Datatyp

    text

    Alias
    NCI Thesaurus Property
    C16950
    NCI Thesaurus ObjectClass
    C3384
    UMLS CUI [1,1]
    C0038002
    UMLS CUI [1,2]
    C0030247
    Splenomegaly by scan or x-ray?
    Beskrivning

    Splenomegaly, Imaging

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3384
    NCI Thesaurus Property
    C19477
    UMLS CUI [1,1]
    C0038002
    UMLS CUI [1,2]
    C1704254
    Palpable Hepatomegaly?
    Beskrivning

    Hepatomegaly, palpation

    Datatyp

    text

    Alias
    NCI Thesaurus Property
    C16950
    NCI Thesaurus ObjectClass
    C3100
    UMLS CUI [1,1]
    C0019209
    UMLS CUI [1,2]
    C0030247
    Hepatomegaly by scan or x-ray?
    Beskrivning

    Hepatomegaly, Imaging

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3100
    NCI Thesaurus Property
    C19477
    UMLS CUI [1,1]
    C0019209
    UMLS CUI [1,2]
    C1704254
    Palpable Lymphadenopathy?
    Beskrivning

    Lymphadenopathy, Palpation

    Datatyp

    boolean

    Alias
    NCI Thesaurus Property
    C16950
    NCI Thesaurus ObjectClass
    C3206
    UMLS CUI [1,1]
    C0497156
    UMLS CUI [1,2]
    C0030247
    Lymphadenopathy by scan or x-ray?
    Beskrivning

    Lymphadenopathy, Imaging

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C3206
    NCI Thesaurus Property
    C19477
    UMLS CUI [1,1]
    C0497156
    UMLS CUI [1,2]
    C1704254
    Immunophenotype
    Beskrivning

    Immunophenotype

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C0079611
    Other, specify
    Beskrivning

    Immunophenotype,Other

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C0079611
    Current Laboratory Values
    Beskrivning

    Current Laboratory Values

    Alias
    UMLS CUI-1
    C1254595
    Date of Blood Values
    Beskrivning

    Sample Collection Date

    Datatyp

    date

    Alias
    UMLS CUI [1]
    C1317250
    HGB
    Beskrivning

    Hemoglobin

    Datatyp

    float

    Alias
    UMLS CUI [1]
    C0019046
    PLTS
    Beskrivning

    Platelets

    Datatyp

    float

    Alias
    UMLS CUI [1]
    C0005821
    WBC
    Beskrivning

    WBC

    Datatyp

    float

    Alias
    UMLS CUI [1]
    C0023508
    Peripheral Blasts
    Beskrivning

    Peripheral Blasts

    Datatyp

    float

    Alias
    UMLS CUI [1]
    C0368761
    Peripheral Neutrophils
    Beskrivning

    Peripheral Neutrophils

    Datatyp

    float

    Alias
    UMLS CUI [1]
    C0858017
    Peripheral Lymphocytes
    Beskrivning

    Lymphocytes

    Datatyp

    float

    Måttenheter
    • %
    Alias
    UMLS CUI [1]
    C2200256
    %
    Peripheral Monocytes
    Beskrivning

    Monocytes

    Datatyp

    float

    Måttenheter
    • %
    Alias
    UMLS CUI [1]
    C1171403
    %
    Date of Bone Marrow Biopsy/Aspiration
    Beskrivning

    Bone Marrow Biopsy Date

    Datatyp

    date

    Alias
    UMLS CUI [1,1]
    C0005954
    UMLS CUI [1,2]
    C0011008
    Marrow Cellularity
    Beskrivning

    Bone Marrow Cellularity

    Datatyp

    float

    Måttenheter
    • %
    Alias
    UMLS CUI [1]
    C1561532
    %
    Marrow Blasts
    Beskrivning

    Bone Marrow Blasts

    Datatyp

    float

    Måttenheter
    • %
    Alias
    UMLS CUI [1]
    C1982687
    %
    Marrow Lymphocytes
    Beskrivning

    Bone Marrow Lymphocytes

    Datatyp

    float

    Måttenheter
    • %
    Alias
    UMLS CUI [1]
    C0427708
    %
    Cellularity Status
    Beskrivning

    Bone Marrow Cellularity

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C1561532
    Comments
    Beskrivning

    Comments

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C0947611
    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
    Beskrivning

    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form

    Alias
    UMLS CUI-1
    C1320722
    SWOG Patient ID
    Beskrivning

    SWOG Patient ID

    Datatyp

    text

    Alias
    UMLS CUI [1,1]
    C2348585
    UMLS CUI [1,2]
    C1519429
    SWOG Study No.
    Beskrivning

    SWOG Study Number

    Datatyp

    text

    Alias
    UMLS CUI [1,1]
    C3274381
    UMLS CUI [1,2]
    C1519429
    Registration Step
    Beskrivning

    Registration Step

    Datatyp

    text

    Alias
    UMLS CUI-1
    C1514821
    Patient Initials
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C2986440
    Institution/Affiliate
    Beskrivning

    Main Member Institution/Affiliate

    Datatyp

    text

    Alias
    UMLS CUI [1]
    C1301943
    Physician
    Beskrivning

    Treating Physician

    Datatyp

    text

    Alias
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C25741
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS CUI [1]
    C1710470
    Tillbaka till toppen

    Similar models

    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 Formulär
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Patient And Disease Description
    C3259023 (UMLS CUI-1)
    Performance Status
    Item
    Zubrod performance status
    text
    C3714786 (UMLS CUI [1])
    Patient Height
    Item
    Height
    float
    C16960 (NCI Thesaurus ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS CUI [1])
    Initial Diagnosis Date
    Item
    Date of First Pathologic Diagnosis
    date
    C2316983 (UMLS CUI [1])
    Item
    FAB Classification
    text
    C25372 (NCI Thesaurus ValueDomain)
    C3161 (NCI Thesaurus ObjectClass)
    C25161 (NCI Thesaurus Property)
    C2984084 (UMLS CUI [1])
    CL.1
    Code List
    FAB Classification
    CL Item
    Disease Is A Mixed Lineage Acute Leukemia (Mixed lineage ALL)
    C0023464 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Disease Classified As Acute Lympoblastic Leukemia (FAB L1)
    C0457324 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Disease Classified As Acute Lymphoblastic Leukemia (fab L2) (FAB L2)
    C0457325 (UMLS CUI-1)
    (Comment:en)
    Item
    Extramedullary Disease Involvement
    text
    C1517060 (UMLS CUI [1,1])
    C0012634 (UMLS CUI [1,2])
    CL.2
    Code List
    Extramedullary Disease Involvement
    CL Item
    Pathology Or Disease Involving The Central Nervous System Present (Central Nervous System)
    C3714787 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Pathology Or Disease Involving The Peripheral Nervous System Present (Peripheral Nervous System)
    C0206417 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Gingival Hypertrophy Present (Gingival Hypertrophy)
    C0017567 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Mediastinal Mass Present (Mediastinal Mass)
    C0240318 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Pathology Or Disease Involving The Skin Present (Skin)
    C1123023 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Other Specified Extramedullary Disease Present (Other, specify)
    C3845569 (UMLS CUI-1)
    (Comment:en)
    Extramedullary Disease, other
    Item
    Other specify
    text
    C1517060 (UMLS CUI [1,1])
    C0012634 (UMLS CUI [1,2])
    Item Group
    Organ Involvement
    C0457577 (UMLS CUI-1)
    Item
    Palpable Splenomegaly?
    text
    C16950 (NCI Thesaurus Property)
    C3384 (NCI Thesaurus ObjectClass)
    C0038002 (UMLS CUI [1,1])
    C0030247 (UMLS CUI [1,2])
    CL.3
    Code List
    Palpable Splenomegaly?
    CL Item
    Palpation Performed And Splenomegaly Present (Yes)
    C1298907 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Palpation Performed And Splenomegaly Absent (No)
    C1298908 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Palpation Of Spleen Not Performed (Not examined)
    C0332129 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Surgically absent (Surgically absent)
    C0259767 (UMLS CUI-1)
    (Comment:en)
    Item
    Splenomegaly by scan or x-ray?
    text
    C3384 (NCI Thesaurus ObjectClass)
    C19477 (NCI Thesaurus Property)
    C0038002 (UMLS CUI [1,1])
    C1704254 (UMLS CUI [1,2])
    CL.4
    Code List
    Splenomegaly by scan or x-ray?
    CL Item
    Imaging Performed And Splenomegaly Present (Yes)
    C1298907 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Imaging Performed And Splenomegaly Absent (No)
    C1298908 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Imaging Of Spleen Not Performed (Not examined)
    C0332129 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Spleen Removed Via Prior Surgery (Surgically absent)
    C0259767 (UMLS CUI-1)
    (Comment:en)
    Item
    Palpable Hepatomegaly?
    text
    C16950 (NCI Thesaurus Property)
    C3100 (NCI Thesaurus ObjectClass)
    C0019209 (UMLS CUI [1,1])
    C0030247 (UMLS CUI [1,2])
    CL.5
    Code List
    Palpable Hepatomegaly?
    CL Item
    Yes (Yes)
    C1298907 (UMLS CUI-1)
    (Comment:en)
    CL Item
    No (No)
    C1298908 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Not examined (Not examined)
    C0332129 (UMLS CUI-1)
    (Comment:en)
    Item
    Hepatomegaly by scan or x-ray?
    text
    C3100 (NCI Thesaurus ObjectClass)
    C19477 (NCI Thesaurus Property)
    C0019209 (UMLS CUI [1,1])
    C1704254 (UMLS CUI [1,2])
    CL.6
    Code List
    Hepatomegaly by scan or x-ray?
    CL Item
    Yes (Yes)
    C1298907 (UMLS CUI-1)
    (Comment:en)
    CL Item
    No (No)
    C1298908 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Not examined (Not examined)
    C0332129 (UMLS CUI-1)
    (Comment:en)
    Lymphadenopathy, Palpation
    Item
    Palpable Lymphadenopathy?
    boolean
    C16950 (NCI Thesaurus Property)
    C3206 (NCI Thesaurus ObjectClass)
    C0497156 (UMLS CUI [1,1])
    C0030247 (UMLS CUI [1,2])
    Item
    Lymphadenopathy by scan or x-ray?
    text
    C3206 (NCI Thesaurus ObjectClass)
    C19477 (NCI Thesaurus Property)
    C0497156 (UMLS CUI [1,1])
    C1704254 (UMLS CUI [1,2])
    CL.8
    Code List
    Lymphadenopathy by scan or x-ray?
    CL Item
    Yes (Yes)
    C1298907 (UMLS CUI-1)
    (Comment:en)
    CL Item
    No (No)
    C1298908 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Not examined (Not examined)
    C0332129 (UMLS CUI-1)
    (Comment:en)
    Item
    Immunophenotype
    text
    C0079611 (UMLS CUI [1])
    CL.9
    Code List
    Immunophenotype
    CL Item
    T-cell Immunophenotype (T-cell)
    C0039194 (UMLS CUI-1)
    (Comment:en)
    CL Item
    pre B-cell (pre B-cell)
    C0312738 (UMLS CUI-1)
    (Comment:en)
    CL Item
    B-cell Immunophenotype (B-cell)
    C0004561 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Unknown (Unknown)
    C0439673 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Other Specified Immunophenotype (Other, specify)
    C3845569 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Indeterminate Immunophenotype (Indeterminate)
    C0205258 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Mixed Cells Immunophenotype (Mixed)
    C0205430 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Non-T/non-B Cell Immunophenotype (Non-T/Non-B)
    C0024265 (UMLS CUI-1)
    (Comment:en)
    Immunophenotype,Other
    Item
    Other, specify
    text
    C0079611 (UMLS CUI [1])
    Item Group
    Current Laboratory Values
    C1254595 (UMLS CUI-1)
    Sample Collection Date
    Item
    Date of Blood Values
    date
    C1317250 (UMLS CUI [1])
    Hemoglobin
    Item
    HGB
    float
    C0019046 (UMLS CUI [1])
    Platelets
    Item
    PLTS
    float
    C0005821 (UMLS CUI [1])
    WBC
    Item
    WBC
    float
    C0023508 (UMLS CUI [1])
    Peripheral Blasts
    Item
    Peripheral Blasts
    float
    C0368761 (UMLS CUI [1])
    Peripheral Neutrophils
    Item
    Peripheral Neutrophils
    float
    C0858017 (UMLS CUI [1])
    Lymphocytes
    Item
    Peripheral Lymphocytes
    float
    C2200256 (UMLS CUI [1])
    Monocytes
    Item
    Peripheral Monocytes
    float
    C1171403 (UMLS CUI [1])
    Bone Marrow Biopsy Date
    Item
    Date of Bone Marrow Biopsy/Aspiration
    date
    C0005954 (UMLS CUI [1,1])
    C0011008 (UMLS CUI [1,2])
    Bone Marrow Cellularity
    Item
    Marrow Cellularity
    float
    C1561532 (UMLS CUI [1])
    Bone Marrow Blasts
    Item
    Marrow Blasts
    float
    C1982687 (UMLS CUI [1])
    Bone Marrow Lymphocytes
    Item
    Marrow Lymphocytes
    float
    C0427708 (UMLS CUI [1])
    Item
    Cellularity Status
    text
    C1561532 (UMLS CUI [1])
    CL.10
    Code List
    Cellularity Status
    CL Item
    Cellularity Status Of Bone Marrow Is Aplasitc (severely Hypocellular) (Aplastic)
    C1368107 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Cellularity Status Of Bone Marrow Is Hypocellular (Hypocellular)
    C1855710 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Cellularity Status Of Bone Marrow Is Normocellular (Normocellular)
    C2960424 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Cellularity Status Of Bone Marrow Is Hypercellular (Hypercellular)
    C0542080 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Cellularity Status Of Bone Marrow Is Packed (intensely Hypercellular) (Packed)
    C1547247 (UMLS CUI-1)
    (Comment:en)
    CL Item
    Cellularity Status Of Bone Marrow Unknown, Procedure Resulted In No Material To Analyze (Dry tap or inaspirable)
    C2238270 (UMLS CUI-1)
    (Comment:en)
    Comments
    Item
    Comments
    text
    C0947611 (UMLS CUI [1])
    Item Group
    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
    C1320722 (UMLS CUI-1)
    SWOG Patient ID
    Item
    SWOG Patient ID
    text
    C2348585 (UMLS CUI [1,1])
    C1519429 (UMLS CUI [1,2])
    SWOG Study Number
    Item
    SWOG Study No.
    text
    C3274381 (UMLS CUI [1,1])
    C1519429 (UMLS CUI [1,2])
    Registration Step
    Item
    Registration Step
    text
    C1514821 (UMLS CUI-1)
    Patient Initials
    Item
    Patient Initials
    text
    C2986440 (UMLS CUI [1])
    Main Member Institution/Affiliate
    Item
    Institution/Affiliate
    text
    C1301943 (UMLS CUI [1])
    Treating Physician
    Item
    Physician
    text
    C25364 (NCI Thesaurus Property)
    C25741 (NCI Thesaurus ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1710470 (UMLS CUI [1])
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