ID

24868

Description

SOUTHWEST ONCOLOGY GROUP LEUKEMIA RESPONSE FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB44CFF-75C7-4219-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB44CFF-75C7-4219-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/20/17 8/20/17 -
Uploaded on

August 20, 2017

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Response - SOUTHWEST ONCOLOGY GROUP LEUKEMIA RESPONSE FORM - 2070922v3.0

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  
Response
Description

Response

Has the patient had a documented clinical assessment for this cancer?
Description

follow up cancer

Data type

integer

Alias
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C0006826
Date of Last Clinical Assessment
Description

Follow-up Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus Property
C25365
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C0006826
UMLS CUI [1,3]
C0011008
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
Description

clinical and hematologic criteria

Data type

integer

Alias
UMLS CUI [1]
C4050094
Date of Complete Response
Description

CRFirstObservedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
UMLS 2011AA ObjectClass
C0871261
NCI Thesaurus Property
C15722
UMLS 2011AA Property
C0700325
Laboratory Values And Extramedullary Disease Involvement
Description

Laboratory Values And Extramedullary Disease Involvement

Alias
UMLS CUI-1
C0022885
UMLS CUI-2
C0012634
UMLS CUI-3
C1517060
Date of Blood Values
Description

Date of Blood Values

Data type

date

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0005834
UMLS CUI [1,3]
C0011008
HGB
Description

Hemoglobin

Data type

float

Alias
UMLS CUI [1]
C0019046
PLTS
Description

PLTS

Data type

float

Alias
UMLS CUI [1]
C0032181
WBC
Description

WBC

Data type

float

Alias
UMLS CUI [1]
C0023508
Peripheral Blasts
Description

Peripheral Blasts

Data type

float

Alias
UMLS CUI [1]
C0523113
Peripheral Neutrophils
Description

Peripheral Neutrophils

Data type

float

Alias
UMLS CUI [1]
C1171400
Peripheral Lymphocytes
Description

Peripheral Lymphocytes

Data type

float

Alias
UMLS CUI [1]
C0200635
Peripheral Monocytes
Description

Peripheral Monocytes

Data type

float

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

Marrow Cellularity

Data type

float

Alias
UMLS CUI [1]
C1561532
Marrow Blasts
Description

Marrow Blasts

Data type

float

Alias
UMLS CUI [1,1]
C0523113
UMLS CUI [1,2]
C0005953
Marrow Lymphocytes
Description

Marrow Lymphocytes

Data type

float

Alias
UMLS CUI [1,1]
C0024264
UMLS CUI [1,2]
C0005953
Cellularity Status
Description

Cellularity Status

Data type

integer

Alias
UMLS CUI [1]
C1561532
Date of Examination for Extramedullary Disease
Description

PatientExtramedullaryDiseaseAssessmentDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C2991
NCI Thesaurus Property-3
C25503
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0012634
UMLS CUI [1,3]
C1517060
UMLS CUI [1,4]
C0011008
Extramedullary Disease Involvement
Description

Extramedullary Disease

Data type

integer

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

Extramedullary Disease

Data type

text

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C1517060
Did the patient receive a lumbar puncture during this reporting period?
Description

lumbar puncture

Data type

boolean

Alias
UMLS CUI [1]
C0037943
date of Lumbar Puncture
Description

date of Lumbar Puncture

Data type

text

Alias
UMLS CUI [1,1]
C0037943
UMLS CUI [1,2]
C0011008
CNS Disease
Description

CNS Disease

Data type

integer

Alias
UMLS CUI [1]
C0007682
Notes
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Ccrr Module For Southwest Oncology Group Leukemia Response Form
Description

Ccrr Module For Southwest Oncology Group Leukemia Response Form

Alias
UMLS CUI-1
C0023418
UMLS CUI-2
C0278627
SWOG Patient ID
Description

Patient ID

Data type

text

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

Study Number

Data type

text

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0600091
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

Institution

Data type

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
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
Cycle
Description

Treatment cycle

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1302181
Reporting Period Start Date
Description

Start Date

Data type

date

Alias
UMLS CUI [1]
C0808070
Reporting Period End Date
Description

End Date

Data type

date

Alias
UMLS CUI [1]
C0806020
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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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Response
Item
Has the patient had a documented clinical assessment for this cancer?
integer
C1522577 (UMLS CUI [1,1])
C0006826 (UMLS CUI [1,2])
CL.1
Code List
Has the patient had a documented clinical assessment for this cancer?
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Follow-up Date
Item
Date of Last Clinical Assessment
date
C2991 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C1522577 (UMLS CUI [1,1])
C0006826 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
integer
C4050094 (UMLS CUI [1])
CL.1
Code List
Did the patient achieve a complete response according to clinical/hematologic criteria during this recording period?
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
CRFirstObservedDate
Item
Date of Complete Response
date
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C15722 (NCI Thesaurus Property)
C0700325 (UMLS 2011AA Property)
Item Group
Laboratory Values And Extramedullary Disease Involvement
C0022885 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
C1517060 (UMLS CUI-3)
Date of Blood Values
Item
Date of Blood Values
date
C0022885 (UMLS CUI [1,1])
C0005834 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Hemoglobin
Item
HGB
float
C0019046 (UMLS CUI [1])
PLTS
Item
PLTS
float
C0032181 (UMLS CUI [1])
WBC
Item
WBC
float
C0023508 (UMLS CUI [1])
Peripheral Blasts
Item
Peripheral Blasts
float
C0523113 (UMLS CUI [1])
Peripheral Neutrophils
Item
Peripheral Neutrophils
float
C1171400 (UMLS CUI [1])
Peripheral Lymphocytes
Item
Peripheral Lymphocytes
float
C0200635 (UMLS CUI [1])
Peripheral 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])
Marrow Cellularity
Item
Marrow Cellularity
float
C1561532 (UMLS CUI [1])
Marrow Blasts
Item
Marrow Blasts
float
C0523113 (UMLS CUI [1,1])
C0005953 (UMLS CUI [1,2])
Marrow Lymphocytes
Item
Marrow Lymphocytes
float
C0024264 (UMLS CUI [1,1])
C0005953 (UMLS CUI [1,2])
Item
Cellularity Status
integer
C1561532 (UMLS CUI [1])
CL.3
Code List
Cellularity Status
CL Item
Cellularity Status Of Bone Marrow Is Aplasitc (severely Hypocellular) (1)
CL Item
Cellularity Status Of Bone Marrow Is Hypocellular (2)
CL Item
Cellularity Status Of Bone Marrow Is Normocellular (3)
CL Item
Cellularity Status Of Bone Marrow Is Hypercellular (4)
CL Item
Cellularity Status Of Bone Marrow Is Packed (intensely Hypercellular) (5)
CL Item
Cellularity Status Of Bone Marrow Unknown, Procedure Resulted In No Material To Analyze (6)
Date of Examination for Extramedullary Disease
Item
Date of Examination for Extramedullary Disease
date
C16960 (NCI Thesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C2991 (NCI Thesaurus Property-2)
C25503 (NCI Thesaurus Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0031809 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C1517060 (UMLS CUI [1,3])
C0011008 (UMLS CUI [1,4])
Item
Extramedullary Disease Involvement
integer
C0012634 (UMLS CUI [1,1])
C1517060 (UMLS CUI [1,2])
CL.4
Code List
Extramedullary Disease Involvement
CL Item
Pathology Or Disease Involving The Peripheral Nervous System Present (1)
CL Item
Gingival Hypertrophy Present (2)
CL Item
Mediastinal Mass Present (3)
CL Item
Pathology Or Disease Involving The Skin Present (4)
CL Item
Other Specified Extramedullary Disease Present (5)
Extramedullary Disease
Item
Other, specify
text
C0012634 (UMLS CUI [1,1])
C1517060 (UMLS CUI [1,2])
lumbar puncture
Item
Did the patient receive a lumbar puncture during this reporting period?
boolean
C0037943 (UMLS CUI [1])
date of Lumbar Puncture
Item
date of Lumbar Puncture
text
C0037943 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
CNS Disease
integer
C0007682 (UMLS CUI [1])
CL.6
Code List
CNS Disease
CL Item
Present (1)
CL Item
No (2)
CL Item
Unknown (3)
Comments
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
Ccrr Module For Southwest Oncology Group Leukemia Response Form
C0023418 (UMLS CUI-1)
C0278627 (UMLS CUI-2)
Patient ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Study Number
Item
SWOG Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Institution
Item
Institution/Affiliate
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Treating Physician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI [1])
Item
Cycle
integer
C0087111 (UMLS CUI [1,1])
C1302181 (UMLS CUI [1,2])
CL.7
Code List
Cycle
CL Item
Current Phase Of Leukemia Treatment For Patient Is Induction (1)
CL Item
Cross-over Induction (2)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Consolidation (3)
Start Date
Item
Reporting Period Start Date
date
C0808070 (UMLS CUI [1])
End Date
Item
Reporting Period End Date
date
C0806020 (UMLS CUI [1])
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