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3253

Description

E2906 Acute Leukemia Disease Assessment Form Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7585B205-C98E-8BDD-E040-BB89AD430415

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7585B205-C98E-8BDD-E040-BB89AD430415

Mots-clés

Versions (2)
  1. 19.09.12 19.09.12 -
  2. 08.01.15 08.01.15 - Martin Dugas
Téléchargé le

19. September 2012

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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    NCT01041703 Response - E2906 Acute Leukemia Disease Assessment Form - 2951828v1.0

    Anglais

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center. Keep a copy for your files. If disease was assessed on more than one date, submit additional forms

    1 Formulaires  
    Unnamed1
    Description

    Unnamed1

    DCI Name
    Description

    CollectedDataFormName

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C19464
    UMLS 2011AA Property
    C0376315
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus ObjectClass
    C25452
    Registration Step (Place ID Label Here)
    Description

    RegistrationStepNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain
    C16154
    UMLS 2011AA ValueDomain
    C1704379
    Patient Initials (Last, First)
    Description

    PatientInitialsName

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    ECOG Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    ECOG Protocol Number
    Description

    ProtocolECOGIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    ECOG Patient ID
    Description

    PatientECOGIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25491
    UMLS 2011AA Property
    C1512162
    Participating Group Protocol Number
    Description

    ProtocolParticipatingIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Patient ID
    Description

    PatientParticipatingIdentifierNumber

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Institution/Affiliate
    Description

    CombinedInstitutionName

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    On Treatment
    Description

    On Treatment

    On Treatment Report Period
    Description

    TreatmentEvaluationPeriodType

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus ObjectClass
    C15368
    Off Treatment
    Description

    Off Treatment

    Off Treatment Report Period (since registration to Step 1 If this form covers an Off Treatment Report Period Choose one)
    Description

    PersonOff-TreatmentTimePeriodType

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property
    C25601
    UMLS 2011AA Property
    C1518544
    NCI Thesaurus Property
    C25207
    UMLS 2011AA Property
    C0040223
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Unnamed2
    Description

    Unnamed2

    Please mark an 'X' if data have been amended. (Please circle amended items in red)
    Description

    DataAmendedText

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Date data amended (s M D Y)
    Description

    DataAmendedDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain
    C25367
    Bone Marrow Biopsy Information
    Description

    Bone Marrow Biopsy Information

    Was bone marrow biopsy done (/aspirate obtained for this reporting period)
    Description

    BoneMarrowBiopsyInd

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus Property
    C15189
    UMLS 2011AA Property
    C0005558
    NCI Thesaurus ObjectClass
    C12431
    UMLS 2011AA ObjectClass
    C0005953
    Date of Bone Marrow Biopsy (second /aspirate if done M D Y Submit copy of bone marrow report with E2906 Source Document Tracking Coversheet attached)
    Description

    BoneMarrowBiopsyDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C15189
    UMLS 2011AA Property
    C0005558
    NCI Thesaurus ObjectClass
    C12431
    UMLS 2011AA ObjectClass
    C0005953
    Date of Bone Marrow Biopsy (second /aspirate if done M D Y Submit copy of bone marrow report with E2906 Source Document Tracking Coversheet attached)
    Description

    BoneMarrowBiopsyDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C15189
    UMLS 2011AA Property
    C0005558
    NCI Thesaurus ObjectClass
    C12431
    UMLS 2011AA ObjectClass
    C0005953
    Mark an 'X' if not done (second bone marrow biopsy/aspirate)
    Description

    DataUnknownText

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C17998
    UMLS 2011AA Property
    C0439673
    Marrow Cellularity (%)
    Description

    LaboratoryProcedureBoneMarrowCellularityOutcomePercentageValue

    Type de données

    double

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C12431
    UMLS 2011AA Property
    C0005953
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property
    C37923
    UMLS 2011AA Property
    C1516377
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    Are all cell lines maturing
    Description

    LaboratoryProcedureCytogeneticAnalysisCellLineOutcomeInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C18280
    UMLS 2011AA Property
    C0752095
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property
    C16403
    UMLS 2011AA Property
    C0007600
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Marrow Blasts (%)
    Description

    LaboratoryProcedureBoneMarrowBlastCellOutcomePercentageValue

    Type de données

    double

    Unités de mesure
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C12431
    UMLS 2011AA Property
    C0005953
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property
    C12918
    UMLS 2011AA Property
    C0368761
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    %
    Are auer rods present?
    Description

    LaboratoryProcedureAuerRodsOutcomeStatus

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C12431
    UMLS 2011AA Property
    C0005953
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property
    C25287
    UMLS 2011AA Property
    C0333828
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Was there evidence of persistence of leukemia associated phenotype by flow cytometry
    Description

    PersistentLeukemiaPhenotypeFlowCytometryFindingInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C3161
    UMLS 2011AA ObjectClass
    C0023418
    NCI Thesaurus ObjectClass
    C43623
    UMLS 2011AA ObjectClass
    C0205322
    NCI Thesaurus ObjectClass
    C16977
    UMLS 2011AA ObjectClass
    C0031437
    NCI Thesaurus Property
    C16585
    UMLS 2011AA Property
    C0016263
    NCI Thesaurus Property
    C3367
    UMLS 2011AA Property
    C0037088
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Were there circulating blasts in peripheral blood
    Description

    PeripheralBloodBlastCellPresentInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass
    C25233
    UMLS 2011AA ObjectClass
    C0205100
    NCI Thesaurus ObjectClass
    C12918
    UMLS 2011AA ObjectClass
    C0368761
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Did the patient achieve morphologic leukemia-free state
    Description

    MorphologicFindingDisease-FreeSurvivalLeukemiaDiagnosisInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C3161
    UMLS 2011AA ObjectClass
    C0023418
    NCI Thesaurus ObjectClass
    C17751
    UMLS 2011AA ObjectClass
    C0242793
    NCI Thesaurus ObjectClass
    C35867
    UMLS 2011AA ObjectClass
    C0700329
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Date patient achieved morphologic leukemia-free state
    Description

    MorphologicFindingDisease-FreeSurvivalLeukemiaDiagnosisDate

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C3161
    UMLS 2011AA ObjectClass
    C0023418
    NCI Thesaurus ObjectClass
    C17751
    UMLS 2011AA ObjectClass
    C0242793
    NCI Thesaurus ObjectClass
    C35867
    UMLS 2011AA ObjectClass
    C0700329
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Did patient achieve PR
    Description

    PartialResponseFirstObservedInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C25755
    UMLS 2011AA ObjectClass
    C0871261
    NCI Thesaurus ObjectClass
    C25378
    UMLS 2011AA ObjectClass
    C0728938
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property
    C25599
    UMLS 2011AA Property
    C1441672
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Date of PR (M D Y)
    Description

    PartialResponseConfirmedDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25755
    UMLS 2011AA ObjectClass
    C0871261
    NCI Thesaurus Property
    C25458
    UMLS 2011AA Property
    C0750484
    NCI Thesaurus ObjectClass
    C25378
    UMLS 2011AA ObjectClass
    C0728938
    Did patient achieve CR
    Description

    CompleteResponseObservedInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25755
    UMLS 2011AA ObjectClass
    C0871261
    NCI Thesaurus ObjectClass
    C25250
    UMLS 2011AA ObjectClass
    C0205197
    NCI Thesaurus Property
    C25599
    UMLS 2011AA Property
    C1441672
    Date of CR (M D Y)
    Description

    CompleteResponseOccurrenceDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25755
    UMLS 2011AA ObjectClass
    C0871261
    NCI Thesaurus ObjectClass
    C25250
    UMLS 2011AA ObjectClass
    C0205197
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Was Complete Remission incomplete (CRi) achieved (If no CR)
    Description

    IncompleteBloodCellCountRecoveryCellularMorphologyCompleteRemissionFirstObservedInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C49160
    UMLS 2011AA ObjectClass
    C0205257
    NCI Thesaurus ObjectClass
    C4870
    UMLS 2011AA ObjectClass
    C0677874
    NCI Thesaurus ObjectClass
    C17768
    UMLS 2011AA ObjectClass
    C2700385
    NCI Thesaurus ObjectClass
    C70827
    UMLS 2011AA ObjectClass
    C0237820
    NCI Thesaurus ObjectClass
    C28133
    UMLS 2011AA ObjectClass
    C0009555
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property
    C25599
    UMLS 2011AA Property
    C1441672
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Date of CRi (M D Y)
    Description

    IncompleteBloodCellCountRecoveryCellularMorphologyCompleteRemissionFirstObservedDate

    Type de données

    date

    Alias
    NCI Thesaurus ObjectClass
    C49160
    UMLS 2011AA ObjectClass
    C0205257
    NCI Thesaurus ObjectClass
    C4870
    UMLS 2011AA ObjectClass
    C0677874
    NCI Thesaurus ObjectClass
    C17768
    UMLS 2011AA ObjectClass
    C2700385
    NCI Thesaurus ObjectClass
    C70827
    UMLS 2011AA ObjectClass
    C0237820
    NCI Thesaurus ObjectClass
    C28133
    UMLS 2011AA ObjectClass
    C0009555
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property
    C25599
    UMLS 2011AA Property
    C1441672
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Is there any extramedullary disease
    Description

    PatientExtramedullaryDiseaseAssessmentInd-3

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C2991
    UMLS 2011AA Property
    C0012634
    NCI Thesaurus Property
    C25503
    UMLS 2011AA Property
    C1517060
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Specify sites
    Description

    DiseaseInvolvedSiteSpecify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25547
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    Comments
    Description

    Comments

    Investigator Signature
    Description

    InvestigatorSignatureText

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    Investigator Signature Date (MM DD YYYY)
    Description

    InvestigatorSignatureDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    Retour au début de la page

    Similar models

    INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center. Keep a copy for your files. If disease was assessed on more than one date, submit additional forms

    1 Formulaires
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Unnamed1
    CollectedDataFormName
    Item
    DCI Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C19464 (NCI Thesaurus Property)
    C0376315 (UMLS 2011AA Property)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus ObjectClass)
    RegistrationStepNumber
    Item
    Registration Step (Place ID Label Here)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C16154 (NCI Thesaurus Property)
    C1704379 (UMLS 2011AA Property)
    C16154 (NCI Thesaurus ValueDomain)
    C1704379 (UMLS 2011AA ValueDomain)
    PatientInitialsName
    Item
    Patient Initials (Last, First)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    ProtocolECOGIdentifierNumber
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    ProtocolECOGIdentifierNumber
    Item
    ECOG Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    PatientECOGIdentifierNumber
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    PatientECOGIdentifierNumber
    Item
    ECOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25491 (NCI Thesaurus Property)
    C1512162 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Group Protocol Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientParticipatingIdentifierNumber
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CombinedInstitutionName
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    Item Group
    On Treatment
    Item
    On Treatment Report Period
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C15368 (NCI Thesaurus ObjectClass)
    CL.1
    Code List
    On Treatment Report Period
    CL Item
    Cycle 1 - Induction (Cycle 1 - Induction)
    CL Item
    Cycle 2 - Induction (Cycle 2 - Induction)
    CL Item
    Cycle 1 - Consolidation (Cycle 1 - Consolidation)
    CL Item
    Cycle 2 - Consolidation (Cycle 2 - Consolidation)
    CL Item
    Cycle 1 - Step 3 (Cycle 1 - Step 3)
    CL Item
    Cycle 2 - Step 3 (Cycle 2 - Step 3)
    CL Item
    Cycle 3 - Step 3 (Cycle 3 - Step 3)
    CL Item
    Cycle 4 - Step 3 (Cycle 4 - Step 3)
    CL Item
    Cycle 5 - Step 3 (Cycle 5 - Step 3)
    CL Item
    Cycle 6 - Step 3 (Cycle 6 - Step 3)
    CL Item
    Cycle 7 - Step 3 (Cycle 7 - Step 3)
    CL Item
    Cycle 8 - Step 3 (Cycle 8 - Step 3)
    CL Item
    Cycle 9 - Step 3 (Cycle 9 - Step 3)
    CL Item
    Cycle 10 - Step 3 (Cycle 10 - Step 3)
    CL Item
    Cycle 11 - Step 3 (Cycle 11 - Step 3)
    CL Item
    Cycle 12 - Step 3 (Cycle 12 - Step 3)
    CL Item
    Cycle 13 - Step 3 (Cycle 13 - Step 3)
    CL Item
    At Transplant (At Transplant)
    Item Group
    Off Treatment
    Item
    Off Treatment Report Period (since registration to Step 1 If this form covers an Off Treatment Report Period Choose one)
    text
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25601 (NCI Thesaurus Property)
    C1518544 (UMLS 2011AA Property)
    C25207 (NCI Thesaurus Property)
    C0040223 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Off Treatment Report Period (since registration to Step 1 If this form covers an Off Treatment Report Period Choose one)
    CL Item
    3 Months (3 Months Post Registration)
    CL Item
    6 Months (6 Months Post Registration)
    CL Item
    9 Months (9 Months Post Registration)
    CL Item
    12 Months (12 Months Post Registration)
    CL Item
    15 Months (15 Months Post Registration)
    CL Item
    18 Months (18 Months Post Registration)
    CL Item
    21 Months Post Registration (21 Months Post Registration)
    CL Item
    2 Years (24 Months Post Registration)
    CL Item
    30 Months (30 Months Post Registration)
    CL Item
    3 Years (36 Months Post Registration)
    CL Item
    42 Months (42 Months Post Registration)
    CL Item
    4 Years (48 Months Post Registration)
    CL Item
    54 Months (54 Months Post Registration)
    CL Item
    5 Years (60 Months Post Registration)
    Item Group
    Unnamed2
    DataAmendedText
    Item
    Please mark an 'X' if data have been amended. (Please circle amended items in red)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    DataAmendedDate
    Item
    Date data amended (s M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    Item Group
    Bone Marrow Biopsy Information
    Item
    Was bone marrow biopsy done (/aspirate obtained for this reporting period)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C15189 (NCI Thesaurus Property)
    C0005558 (UMLS 2011AA Property)
    C12431 (NCI Thesaurus ObjectClass)
    C0005953 (UMLS 2011AA ObjectClass)
    CL.3
    Code List
    Was bone marrow biopsy done (/aspirate obtained for this reporting period)
    CL Item
    No (no)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    BoneMarrowBiopsyDate
    Item
    Date of Bone Marrow Biopsy (second /aspirate if done M D Y Submit copy of bone marrow report with E2906 Source Document Tracking Coversheet attached)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C15189 (NCI Thesaurus Property)
    C0005558 (UMLS 2011AA Property)
    C12431 (NCI Thesaurus ObjectClass)
    C0005953 (UMLS 2011AA ObjectClass)
    BoneMarrowBiopsyDate
    Item
    Date of Bone Marrow Biopsy (second /aspirate if done M D Y Submit copy of bone marrow report with E2906 Source Document Tracking Coversheet attached)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C15189 (NCI Thesaurus Property)
    C0005558 (UMLS 2011AA Property)
    C12431 (NCI Thesaurus ObjectClass)
    C0005953 (UMLS 2011AA ObjectClass)
    DataUnknownText
    Item
    Mark an 'X' if not done (second bone marrow biopsy/aspirate)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C17998 (NCI Thesaurus Property)
    C0439673 (UMLS 2011AA Property)
    LaboratoryProcedureBoneMarrowCellularityOutcomePercentageValue
    Item
    Marrow Cellularity (%)
    double
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C12431 (NCI Thesaurus Property)
    C0005953 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C37923 (NCI Thesaurus Property)
    C1516377 (UMLS 2011AA Property)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    Item
    Are all cell lines maturing
    text
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C18280 (NCI Thesaurus Property)
    C0752095 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C16403 (NCI Thesaurus Property)
    C0007600 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Are all cell lines maturing
    CL Item
    No (no)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    LaboratoryProcedureBoneMarrowBlastCellOutcomePercentageValue
    Item
    Marrow Blasts (%)
    double
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C12431 (NCI Thesaurus Property)
    C0005953 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C12918 (NCI Thesaurus Property)
    C0368761 (UMLS 2011AA Property)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    Item
    Are auer rods present?
    text
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C12431 (NCI Thesaurus Property)
    C0005953 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C25287 (NCI Thesaurus Property)
    C0333828 (UMLS 2011AA Property)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Are auer rods present?
    CL Item
    Auer Rods Absent From Bone Marrow (Absent)
    CL Item
    Auer Rods Present In Bone Marrow (Present)
    Item
    Was there evidence of persistence of leukemia associated phenotype by flow cytometry
    text
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C43623 (NCI Thesaurus ObjectClass)
    C0205322 (UMLS 2011AA ObjectClass)
    C16977 (NCI Thesaurus ObjectClass)
    C0031437 (UMLS 2011AA ObjectClass)
    C16585 (NCI Thesaurus Property)
    C0016263 (UMLS 2011AA Property)
    C3367 (NCI Thesaurus Property)
    C0037088 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.6
    Code List
    Was there evidence of persistence of leukemia associated phenotype by flow cytometry
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Were there circulating blasts in peripheral blood
    text
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C25233 (NCI Thesaurus ObjectClass)
    C0205100 (UMLS 2011AA ObjectClass)
    C12918 (NCI Thesaurus ObjectClass)
    C0368761 (UMLS 2011AA ObjectClass)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.7
    Code List
    Were there circulating blasts in peripheral blood
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Did the patient achieve morphologic leukemia-free state
    text
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C17751 (NCI Thesaurus ObjectClass)
    C0242793 (UMLS 2011AA ObjectClass)
    C35867 (NCI Thesaurus ObjectClass)
    C0700329 (UMLS 2011AA ObjectClass)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.8
    Code List
    Did the patient achieve morphologic leukemia-free state
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    MorphologicFindingDisease-FreeSurvivalLeukemiaDiagnosisDate
    Item
    Date patient achieved morphologic leukemia-free state
    date
    C3161 (NCI Thesaurus ObjectClass)
    C0023418 (UMLS 2011AA ObjectClass)
    C17751 (NCI Thesaurus ObjectClass)
    C0242793 (UMLS 2011AA ObjectClass)
    C35867 (NCI Thesaurus ObjectClass)
    C0700329 (UMLS 2011AA ObjectClass)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Did patient achieve PR
    text
    C25755 (NCI Thesaurus ObjectClass)
    C0871261 (UMLS 2011AA ObjectClass)
    C25378 (NCI Thesaurus ObjectClass)
    C0728938 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C25599 (NCI Thesaurus Property)
    C1441672 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.9
    Code List
    Did patient achieve PR
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    PartialResponseConfirmedDate
    Item
    Date of PR (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25755 (NCI Thesaurus ObjectClass)
    C0871261 (UMLS 2011AA ObjectClass)
    C25458 (NCI Thesaurus Property)
    C0750484 (UMLS 2011AA Property)
    C25378 (NCI Thesaurus ObjectClass)
    C0728938 (UMLS 2011AA ObjectClass)
    Item
    Did patient achieve CR
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25755 (NCI Thesaurus ObjectClass)
    C0871261 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus ObjectClass)
    C0205197 (UMLS 2011AA ObjectClass)
    C25599 (NCI Thesaurus Property)
    C1441672 (UMLS 2011AA Property)
    CL.10
    Code List
    Did patient achieve CR
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CompleteResponseOccurrenceDate
    Item
    Date of CR (M D Y)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25755 (NCI Thesaurus ObjectClass)
    C0871261 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus ObjectClass)
    C0205197 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    Item
    Was Complete Remission incomplete (CRi) achieved (If no CR)
    text
    C49160 (NCI Thesaurus ObjectClass)
    C0205257 (UMLS 2011AA ObjectClass)
    C4870 (NCI Thesaurus ObjectClass)
    C0677874 (UMLS 2011AA ObjectClass)
    C17768 (NCI Thesaurus ObjectClass)
    C2700385 (UMLS 2011AA ObjectClass)
    C70827 (NCI Thesaurus ObjectClass)
    C0237820 (UMLS 2011AA ObjectClass)
    C28133 (NCI Thesaurus ObjectClass)
    C0009555 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C25599 (NCI Thesaurus Property)
    C1441672 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    Was Complete Remission incomplete (CRi) achieved (If no CR)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    IncompleteBloodCellCountRecoveryCellularMorphologyCompleteRemissionFirstObservedDate
    Item
    Date of CRi (M D Y)
    date
    C49160 (NCI Thesaurus ObjectClass)
    C0205257 (UMLS 2011AA ObjectClass)
    C4870 (NCI Thesaurus ObjectClass)
    C0677874 (UMLS 2011AA ObjectClass)
    C17768 (NCI Thesaurus ObjectClass)
    C2700385 (UMLS 2011AA ObjectClass)
    C70827 (NCI Thesaurus ObjectClass)
    C0237820 (UMLS 2011AA ObjectClass)
    C28133 (NCI Thesaurus ObjectClass)
    C0009555 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C25599 (NCI Thesaurus Property)
    C1441672 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Is there any extramedullary disease
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C2991 (NCI Thesaurus Property)
    C0012634 (UMLS 2011AA Property)
    C25503 (NCI Thesaurus Property)
    C1517060 (UMLS 2011AA Property)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    CL.12
    Code List
    Is there any extramedullary disease
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    DiseaseInvolvedSiteSpecify
    Item
    Specify sites
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25547 (NCI Thesaurus Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    Item Group
    Comments
    InvestigatorSignatureText
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    InvestigatorSignatureDate
    Item
    Investigator Signature Date (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
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