ID

24499

Description

S0100 PATHOLOGY SUBMISSION FORM - LEUKEMIA ADDENDUM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB41C46-31DA-419A-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB41C46-31DA-419A-E034-0003BA12F5E7

Keywords

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

August 3, 2017

DOI

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License

Creative Commons BY-NC 3.0
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SWOG Leukemia

English

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Notes section at the bottom of the form. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms  
S0100 Pathology Submission Form - Leukemia Addendum
Description

S0100 Pathology Submission Form - Leukemia Addendum

Alias
UMLS CUI-1
C1320722
SWOG Patient No.
Description

SWOG Patient ID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1519429
Protocol Step
Description

Treatment Step

Data type

text

Alias
UMLS CUI [1]
C1704379
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Institution/Member
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
Date Registered
Description

Registration Date

Data type

date

Alias
UMLS CUI [1,1]
C0421512
UMLS CUI [1,2]
C0011008
Date sample obtained
Description

Specimen Collection Date

Data type

date

Alias
UMLS CUI [1]
C1302413
Time sample obtained
Description

Specimen Collection Time

Data type

time

Alias
UMLS CUI [1]
C4064021
Disease
Description

Leukemia/MDS Classification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C3161
NCI Thesaurus Property
C25161
UMLS CUI [1,1]
C0023418
UMLS CUI [1,2]
C0008902
Other Leukemia
Description

Leukemia Classification, other

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C3161
NCI Thesaurus Property
C25161
UMLS CUI [1,1]
C0023418
UMLS CUI [1,2]
C0008902
Other disease, specify
Description

Other disease

Data type

text

Alias
UMLS CUI [1]
C2359476
Special Stains used at Institution and Results
Description

Special Stains

Data type

text

Alias
UMLS CUI [1]
C3825641
Other, specify stain
Description

Stain, other

Data type

text

Alias
UMLS CUI [1]
C3825641
Sudan black, Result
Description

Sudan black

Data type

text

Alias
UMLS CUI [1]
C0588374
Myeloperoxidase chloroacetate, Result
Description

Myeloperoxidase

Data type

text

Alias
UMLS CUI [1]
C0440053
Specific esterase, Result
Description

Specific esterase

Data type

text

Alias
UMLS CUI [1]
C1293971
Nonspecific esterase, Result
Description

Nonspecific esterase

Data type

text

Alias
UMLS CUI [1]
C1293970
Other, specify stain, Result
Description

Other stain result

Data type

text

Alias
UMLS CUI [1]
C3825641
Non-specific esterase
Description

Nonspecific esterase

Data type

text

Alias
UMLS CUI [1]
C0440047
other, specify
Description

other, specify

Data type

text

Alias
UMLS CUI [1]
C3845569
Notes
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
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Similar models

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Notes section at the bottom of the form. 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
S0100 Pathology Submission Form - Leukemia Addendum
C1320722 (UMLS CUI-1)
SWOG Patient ID
Item
SWOG Patient No.
text
C2348585 (UMLS CUI [1,1])
C1519429 (UMLS CUI [1,2])
Treatment Step
Item
Protocol Step
text
C1704379 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Main Member Institution/Affiliate
Item
Institution/Member
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])
Registration Date
Item
Date Registered
date
C0421512 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Specimen Collection Date
Item
Date sample obtained
date
C1302413 (UMLS CUI [1])
Specimen Collection Time
Item
Time sample obtained
time
C4064021 (UMLS CUI [1])
Item
Disease
text
C25372 (NCI Thesaurus ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C0023418 (UMLS CUI [1,1])
C0008902 (UMLS CUI [1,2])
CL.1
Code List
Disease
CL Item
ALL (ALL, Other)
C0023449 (UMLS CUI-1)
(Comment:en)
CL Item
AML, Other (AML, Other)
C0023467 (UMLS CUI-1)
(Comment:en)
CL Item
Biphenotypic Leukemia (Biphenotypic)
C0023464 (UMLS CUI-1)
(Comment:en)
CL Item
Hairy Cell Leukemia (Hairy cell leukemia)
C0023443 (UMLS CUI-1)
(Comment:en)
CL Item
ALL, Not Otherwise Specified (ALL NOS)
C0023449 (UMLS CUI-1)
C1518425 (UMLS CUI-2)
(Comment:en)
CL Item
Acute Lymphoblastic Leukemia (FAB L3) (FAB L3)
C0457326 (UMLS CUI-1)
(Comment:en)
CL Item
Acute Lympoblastic Leukemia (FAB L1) (FAB L1)
C0457324 (UMLS CUI-1)
(Comment:en)
CL Item
Acute Lymphoblastic Leukemia (FAB L2) (FAB L2)
C0457325 (UMLS CUI-1)
(Comment:en)
CL Item
AML, Not Otherwise Specified (AML NOS)
C0023467 (UMLS CUI-1)
C1518425 (UMLS CUI-2)
(Comment:en)
CL Item
Acute Myeloid Leukemia w/o Maturation (FAB M1) (FAB M1)
C0457328 (UMLS CUI-1)
(Comment:en)
CL Item
Acute Myeloid Leukemia with Maturation (FAB M2) (FAB M2)
C0457352 (UMLS CUI-1)
(Comment:en)
CL Item
Acute Promyelocytic Leukemia (FAB M3) (FAB M3)
C0457329 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M3V (FAB M3V)
C0563636 (UMLS CUI-1)
(Comment:en)
CL Item
Disease Classified As Acute Myelomonocytic Leukemia (FAB M4) (FAB M4)
C0457331 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M4eo (FAB M4eo)
C1332156 (UMLS CUI-1)
(Comment:en)
CL Item
Disease Classified As Acute Monocytic Leukemia (FAB M5) (FAB M5)
C0457333 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M5a (FAB M5a)
C0457334 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M5b (FAB M5b)
C0457335 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M6 (FAB M6)
C0457336 (UMLS CUI-1)
(Comment:en)
CL Item
Disease Classified As Acute Megakaryoblastic Leukemia (FAB M7) (FAB M7)
C0457337 (UMLS CUI-1)
(Comment:en)
CL Item
Acute myelogenous leukemia M0 (FAB M0)
C0457327 (UMLS CUI-1)
(Comment:en)
CL Item
Chronic Lymphocytic Leukemia (CLL)
C0023434 (UMLS CUI-1)
(Comment:en)
CL Item
CML, Not Otherwise Specified (CML NOS)
C0023473 (UMLS CUI-1)
C1518425 (UMLS CUI-2)
(Comment:en)
CL Item
Chronic Myelogenous Leukemia, Chronic Phase (CML, chronic phase)
C0023474 (UMLS CUI-1)
(Comment:en)
CL Item
Chronic Myelogenous Leukemia, Blast Crisis (CML, blast crisis)
C0005699 (UMLS CUI-1)
(Comment:en)
CL Item
Chronic Myelogenous Leukemia, Accelerating Phase, Lymphoid (CML, accelerating phase)
C1739405 (UMLS CUI-1)
(Comment:en)
CL Item
Refractory Anemia (MDS RA)
C0002893 (UMLS CUI-1)
(Comment:en)
CL Item
Refractory Anemia with Ring Sideroblasts (MDS RARS)
C1264195 (UMLS CUI-1)
(Comment:en)
CL Item
Disease Classified As Refractory Anemia with excess Blasts (MDS RAEB)
C0002894 (UMLS CUI-1)
(Comment:en)
CL Item
Refractory Anemia with Excess Blasts In Transformation (MDS RAEB-T)
C0280028 (UMLS CUI-1)
(Comment:en)
CL Item
Chronic Myelomonocytic Leukemia (CMML)
C0023480 (UMLS CUI-1)
(Comment:en)
CL Item
Specified Other Leukemia (Leukemia, other)
C0029812 (UMLS CUI-1)
(Comment:en)
CL Item
Myelodysplastic Syndrome NOS (MDS NOS)
C3463824 (UMLS CUI-1)
C1518425 (UMLS CUI-2)
(Comment:en)
Leukemia Classification, other
Item
Other Leukemia
text
C25372 (NCI Thesaurus ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C0023418 (UMLS CUI [1,1])
C0008902 (UMLS CUI [1,2])
Other disease
Item
Other disease, specify
text
C2359476 (UMLS CUI [1])
Item
Special Stains used at Institution and Results
text
C3825641 (UMLS CUI [1])
CL.2
Code List
Special Stains used at Institution and Results
CL Item
Sudan Black (Sudan black)
C0588374 (UMLS CUI-1)
(Comment:en)
CL Item
Myeloperoxidase Chloroacetate (Myeloperoxidase chloroacetate)
C0440053 (UMLS CUI-1)
(Comment:en)
CL Item
Specific Esterase (Specific esterase)
C1293971 (UMLS CUI-1)
(Comment:en)
CL Item
Non Specific Esterase (Non specific esterase)
C1293970 (UMLS CUI-1)
(Comment:en)
CL Item
Other, Specify Stain (Other, specify stain)
C3825641 (UMLS CUI-1)
(Comment:en)
Stain, other
Item
Other, specify stain
text
C3825641 (UMLS CUI [1])
Sudan black
Item
Sudan black, Result
text
C0588374 (UMLS CUI [1])
Myeloperoxidase
Item
Myeloperoxidase chloroacetate, Result
text
C0440053 (UMLS CUI [1])
Specific esterase
Item
Specific esterase, Result
text
C1293971 (UMLS CUI [1])
Nonspecific esterase
Item
Nonspecific esterase, Result
text
C1293970 (UMLS CUI [1])
Other stain result
Item
Other, specify stain, Result
text
C3825641 (UMLS CUI [1])
Item
Non-specific esterase
text
C0440047 (UMLS CUI [1])
CL.3
Code List
Non-specific esterase
CL Item
Naphtyl-asd-acetate (naphtyl-ASD-acetate)
CL Item
Alpha-naphthyl Butyrate (alpha-naphthyl butyrate)
C0051445 (NCI Metathesaurus)
CL Item
Alpha-naphthyl Acetate (alpha-naphthyl acetate)
C0051444 (NCI Metathesaurus)
CL Item
Other, Specify (other, specify)
other, specify
Item
other, specify
text
C3845569 (UMLS CUI [1])
Comments
Item
Notes
text
C0947611 (UMLS CUI [1])
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