ID

24486

Description

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

Lien

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

Mots-clés

Versions (3)
  1. 19/09/2012 19/09/2012 -
  2. 02/08/2017 02/08/2017 - Martin Dugas
  3. 02/08/2017 02/08/2017 - Martin Dugas
Téléchargé le

2 août 2017

DOI

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Licence

Creative Commons BY-NC 3.0
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PRESTUDY FORM

Anglais

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 Formulaires  
Patient And Disease Description
Description

Patient And Disease Description

Alias
UMLS CUI-1
C3259023
Zubrod performance status
Description

Performance Status

Type de données

text

Alias
UMLS CUI [1]
C3714786
Height
Description

Patient Height

Type de données

float

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

Initial Diagnosis Date

Type de données

date

Alias
UMLS CUI [1]
C2316983
FAB Classification
Description

Leukemia/MDS Classification

Type de données

text

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

Extramedullary Disease

Type de données

text

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

Extramedullary Disease, other

Type de données

text

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

Organ Involvement

Alias
UMLS CUI-1
C0457577
Palpable Splenomegaly?
Description

Splenomegaly, Palpation

Type de données

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?
Description

Splenomegaly, Imaging

Type de données

text

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

Hepatomegaly, palpation

Type de données

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?
Description

Hepatomegaly, Imaging

Type de données

text

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

Lymphadenopathy, Palpation

Type de données

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?
Description

Lymphadenopathy, Imaging

Type de données

text

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

Immunophenotype

Type de données

text

Alias
UMLS CUI [1]
C0079611
Other, specify
Description

Immunophenotype,Other

Type de données

text

Alias
UMLS CUI [1]
C0079611
Current Laboratory Values
Description

Current Laboratory Values

Alias
UMLS CUI-1
C1254595
Date of Blood Values
Description

Sample Collection Date

Type de données

date

Alias
UMLS CUI [1]
C1317250
HGB
Description

Hemoglobin

Type de données

float

Alias
UMLS CUI [1]
C0019046
PLTS
Description

Platelets

Type de données

float

Alias
UMLS CUI [1]
C0005821
WBC
Description

WBC

Type de données

float

Alias
UMLS CUI [1]
C0023508
Peripheral Blasts
Description

Peripheral Blasts

Type de données

float

Alias
UMLS CUI [1]
C0368761
Peripheral Neutrophils
Description

Peripheral Neutrophils

Type de données

float

Alias
UMLS CUI [1]
C0858017
Peripheral Lymphocytes
Description

Lymphocytes

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C2200256
%
Peripheral Monocytes
Description

Monocytes

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C1171403
%
Date of Bone Marrow Biopsy/Aspiration
Description

Bone Marrow Biopsy Date

Type de données

date

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

Bone Marrow Cellularity

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C1561532
%
Marrow Blasts
Description

Bone Marrow Blasts

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C1982687
%
Marrow Lymphocytes
Description

Bone Marrow Lymphocytes

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C0427708
%
Cellularity Status
Description

Bone Marrow Cellularity

Type de données

text

Alias
UMLS CUI [1]
C1561532
Comments
Description

Comments

Type de données

text

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

Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form

Alias
UMLS CUI-1
C1320722
SWOG Patient ID
Description

SWOG Patient ID

Type de données

text

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

SWOG Study Number

Type de données

text

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

Registration Step

Type de données

text

Alias
UMLS CUI-1
C1514821
Patient Initials
Description

Patient Initials

Type de données

text

Alias
UMLS CUI [1]
C2986440
Institution/Affiliate
Description

Main Member Institution/Affiliate

Type de données

text

Alias
UMLS CUI [1]
C1301943
Physician
Description

Treating Physician

Type de données

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C25705
UMLS CUI [1]
C1710470
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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 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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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