ID

24487

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

Link

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

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 8/2/17 8/2/17 - Martin Dugas
  3. 8/2/17 8/2/17 - Martin Dugas
Uploaded on

August 2, 2017

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

ACUTE LYMPHOBLASTIC LEUKEMIA, previously untreated

English

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 forms  
Patient And Disease Description
Description

Patient And Disease Description

Alias
UMLS CUI-1
C3259023
Zubrod performance status
Description

Performance Status

Data type

text

Alias
UMLS CUI [1]
C3714786
Height
Description

Patient Height

Data type

float

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

Initial Diagnosis Date

Data type

date

Alias
UMLS CUI [1]
C2316983
FAB Classification
Description

Leukemia/MDS Classification

Data type

text

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

Extramedullary Disease

Data type

text

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

Extramedullary Disease, other

Data type

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

Data type

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

Data type

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

Data type

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

Data type

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

Data type

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

Data type

text

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

Immunophenotype

Data type

text

Alias
UMLS CUI [1]
C0079611
Other, specify
Description

Immunophenotype,Other

Data type

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

Data type

date

Alias
UMLS CUI [1]
C1317250
HGB
Description

Hemoglobin

Data type

float

Alias
UMLS CUI [1]
C0019046
PLTS
Description

Platelets

Data type

float

Alias
UMLS CUI [1]
C0005821
WBC
Description

WBC

Data type

float

Alias
UMLS CUI [1]
C0023508
Peripheral Blasts
Description

Peripheral Blasts

Data type

float

Alias
UMLS CUI [1]
C0368761
Peripheral Neutrophils
Description

Peripheral Neutrophils

Data type

float

Alias
UMLS CUI [1]
C0858017
Peripheral Lymphocytes
Description

Lymphocytes

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C2200256
%
Peripheral Monocytes
Description

Monocytes

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C1171403
%
Date of Bone Marrow Biopsy/Aspiration
Description

Bone Marrow Biopsy Date

Data type

date

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

Bone Marrow Cellularity

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C1561532
%
Marrow Blasts
Description

Bone Marrow Blasts

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C1982687
%
Marrow Lymphocytes
Description

Bone Marrow Lymphocytes

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0427708
%
Cellularity Status
Description

Bone Marrow Cellularity

Data type

text

Alias
UMLS CUI [1]
C1561532
Comments
Description

Comments

Data type

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

Data type

text

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

SWOG Study Number

Data type

text

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

Registration Step

Data type

text

Alias
UMLS CUI-1
C1514821
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Institution/Affiliate
Description

Main Member Institution/Affiliate

Data type

text

Alias
UMLS CUI [1]
C1301943
Physician
Description

Treating Physician

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C25705
UMLS CUI [1]
C1710470
Back to the top of the page

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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])
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial