ID

368

Beskrivning

E1900 Long-Term Follow-up Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294868-3C8F-2FCA-E034-0003BA0B1A09

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294868-3C8F-2FCA-E034-0003BA0B1A09

Nyckelord

Versioner (2)
  1. 2012-05-25 2012-05-25 -
  2. 2015-01-10 2015-01-10 - Martin Dugas
Uppladdad den

25 maj 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT00049517 Follow-Up - E1900 Long-Term Follow-up Form - 2054137v3.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: E1900 Long-Term Follow-up Form
    1. No Instruction available.
Unnamed1
Beskrivning

Unnamed1

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient?s Name
Beskrivning

Patient'sName

Datatyp

text

ECOG Protocol No.
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Protocol No.
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Patient ID
Beskrivning

ECOGPatientID

Datatyp

text

ECOG Patient ID
Beskrivning

ECOGPatientID

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Participating Group Patient ID
Beskrivning

ParticipatingGroupPatientID

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Beskrivning

AmendedDataInd

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Reporting Period Start Date: (M D Y)
Beskrivning

IntervalReportFromDate

Datatyp

date

Reporting Period End Date: (M D Y)
Beskrivning

IntervalReportToDate

Datatyp

date

Vital Status
Beskrivning

Vital Status

Patient's Vital Status
Beskrivning

Patient'sVitalStatus

Datatyp

text

Date of Last Contact or Death (M D Y)
Beskrivning

DeathDate/LastContactDate

Datatyp

date

Primary Cause of Death
Beskrivning

DeathReason

Datatyp

text

Describe cause of death
Beskrivning

DeathReason,Specify

Datatyp

text

Disease Follow-up Status
Beskrivning

Disease Follow-up Status

Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)?
Beskrivning

CancerFollow-upStatusInd

Datatyp

text

Date of last clinical assessment (If yes)
Beskrivning

CancerFollow-upStatusDate

Datatyp

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of Relapse
Beskrivning

Notice Of Relapse

Has the patient developed a first relapse that has not been previously reported?
Beskrivning

ProgressionInd

Datatyp

text

Date of relapse
Beskrivning

ProgressionDate

Datatyp

date

Did a physician make a formal diagnosis of relapse? (If no or unknown, specify basis of PD in Comments)
Beskrivning

PhysicianProgressiveDiagnosisInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus Property
C25254
UMLS 2011AA Property
C0205329
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Notice Of New Primary
Beskrivning

Notice Of New Primary

Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Beskrivning

NewPrimaryCancerInd

Datatyp

text

Site(s) of new primary
Beskrivning

NewPrimarySite

Datatyp

text

Toxicity
Beskrivning

Toxicity

Has the patient experienced any severe (Grade >= 3) long term toxicity that has not been previously reported?
Beskrivning

LateAdverseEventInd

Datatyp

text

Non-protocol Therapy
Beskrivning

Non-protocol Therapy

Has the patient received any non-protocol cancer therapy prior to first relapse (not previously reported)?
Beskrivning

Hasthepatientreceivedanynon-protocolcancertherapypriortofirstprogression(notpreviouslyreported)?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Transfusions
Beskrivning

Transfusions

Number of platlet transfusions (this reporting period)
Beskrivning

PlateletTransfusionReceivedUnitCount

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C15366
UMLS 2011AA ObjectClass
C0086818
Date of most recent platelet transfusion
Beskrivning

PlateletTransfusionReceivedMostRecentDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ObjectClass
C15366
UMLS 2011AA ObjectClass
C0086818
NCI Thesaurus ValueDomain
C25577
UMLS 2011AA ValueDomain
C1513491
Number of RBC transfusions (this reporting period)
Beskrivning

PackedRedBloodCellTransfusionReceivedUnitCount

Datatyp

double

Alias
NCI Thesaurus ValueDomain
C44278
UMLS 2011AA ValueDomain
C0439148
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C15409
UMLS 2011AA ObjectClass
C0199962
Date of most recent RBC transfusion
Beskrivning

PackedRedBloodCellTransfusionReceivedMostRecentDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus ObjectClass
C15409
UMLS 2011AA ObjectClass
C0199962
NCI Thesaurus ValueDomain
C25577
UMLS 2011AA ValueDomain
C1513491
Comments
Beskrivning

Comments

Comments
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beskrivning

InvestigatorSignatureDate

Datatyp

date

Ccrr Module For E1900 Long-term Follow-up Form
Beskrivning

Ccrr Module For E1900 Long-term Follow-up Form

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: E1900 Long-Term Follow-up Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IntervalReportFromDate
Item
Reporting Period Start Date: (M D Y)
date
IntervalReportToDate
Item
Reporting Period End Date: (M D Y)
date
Item Group
Vital Status
Item
Patient's Vital Status
text
CL.2
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
Date of Last Contact or Death (M D Y)
date
Item
Primary Cause of Death
text
CL.3
Code List
Primary Cause of Death
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death
text
Item Group
Disease Follow-up Status
Item
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)?
text
CL.4
Code List
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Date of last clinical assessment (If yes)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Notice Of Relapse
Item
Has the patient developed a first relapse that has not been previously reported?
text
CL.5
Code List
Has the patient developed a first relapse that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate
Item
Date of relapse
date
Item
Did a physician make a formal diagnosis of relapse? (If no or unknown, specify basis of PD in Comments)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25254 (NCI Thesaurus Property)
C0205329 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
CL.6
Code List
Did a physician make a formal diagnosis of relapse? (If no or unknown, specify basis of PD in Comments)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Notice Of New Primary
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
text
CL.7
Code List
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimarySite
Item
Site(s) of new primary
text
Item Group
Toxicity
Item
Has the patient experienced any severe (Grade >= 3) long term toxicity that has not been previously reported?
text
CL.8
Code List
Has the patient experienced any severe (Grade >= 3) long term toxicity that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Non-protocol Therapy
Item
Has the patient received any non-protocol cancer therapy prior to first relapse (not previously reported)?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.9
Code List
Has the patient received any non-protocol cancer therapy prior to first relapse (not previously reported)?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Transfusions
PlateletTransfusionReceivedUnitCount
Item
Number of platlet transfusions (this reporting period)
double
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS 2011AA ObjectClass)
PlateletTransfusionReceivedMostRecentDate
Item
Date of most recent platelet transfusion
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS 2011AA ObjectClass)
C25577 (NCI Thesaurus ValueDomain)
C1513491 (UMLS 2011AA ValueDomain)
PackedRedBloodCellTransfusionReceivedUnitCount
Item
Number of RBC transfusions (this reporting period)
double
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C15409 (NCI Thesaurus ObjectClass)
C0199962 (UMLS 2011AA ObjectClass)
PackedRedBloodCellTransfusionReceivedMostRecentDate
Item
Date of most recent RBC transfusion
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C15409 (NCI Thesaurus ObjectClass)
C0199962 (UMLS 2011AA ObjectClass)
C25577 (NCI Thesaurus ValueDomain)
C1513491 (UMLS 2011AA ValueDomain)
Item Group
Comments
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For E1900 Long-term Follow-up Form
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