ID

43115

Description

NCT00057811 CHILDREN'S ONCOLOGY GROUP CYTOGENETICS REPORTING FORM [ANHL01P1] Rituximab, Rasburicase, and Combination Chemotherapy in Treating Young Patients With Newly Diagnosed Advanced B-Cell Leukemia or Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BA472941-6B83-4501-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BA472941-6B83-4501-E034-0003BA12F5E7

Keywords

Versions (4)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
  4. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00057811 CHILDREN'S ONCOLOGY GROUP CYTOGENETICS REPORTING FORM [ANHL01P1]

English

No Instruction available.

1 forms  
  1. StudyEvent: CHILDREN'S ONCOLOGY GROUP CYTOGENETICS REPORTING FORM [ANHL01P1]
    1. No Instruction available.
Header
Description

Header

Institution
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution Personnel
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Institution Patient Identifier
Description

PatientCOGIdentifierNumber

Data type

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-2
C39353
UMLS 2011AA Property-2
C1516477
Institution Patient Identifier
Description

PatientCOGIdentifierNumber

Data type

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-2
C39353
UMLS 2011AA Property-2
C1516477
Today's date
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Date worksheet entered into RDE
Description

DataEnteredDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C37949
UMLS 2011AA Property
C1521975
Miscellaneous Patient Information
Description

Miscellaneous Patient Information

Sex (Required field)
Description

Gender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS CUI-1
C0079399
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17357
If not at study entry, was the primary diagnosis specimen submitted to a cytogenetics laboratory (Required field)
Description

SpecimenLabSubmittedInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Specimen Time (Choose one)
Description

SpecimenCollectedPeriodType

Data type

text

Alias
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
please specify [specimen time] (Text)
Description

SpecimenCollectedPeriodSpecify

Data type

text

Alias
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Cytogenetics Laboratory Specimen Number (Required field)
Description

SpecimenIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Data Specimen Collected (mm/dd/yyyy)
Description

SpecimenLaboratoryProcedureCollectionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25453
UMLS 2011AA Property
C1516698
NCI Thesaurus Property-2
C25294
UMLS 2011AA Property-2
C0022885
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Date Specimen Received in Cytogenetics Laboratory (mm/dd/yyyy)
Description

SpecimenLaboratoryReceivedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property-2
C37984
UMLS 2011AA Property-2
C0022877
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Specimen Type (Required field)
Description

LeukemiaSpecimenCellSourceType

Data type

text

Alias
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus ObjectClass-2
C19157
UMLS 2011AA ObjectClass-2
C0370003
NCI Thesaurus Property
C12508
UMLS 2011AA Property
C0007634
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
please specify [specimen type] (Text)
Description

SpecimenCellSourceSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C12508
UMLS 2011AA Property
C0007634
NCI Thesaurus Property-2
C25683
UMLS 2011AA Property-2
C0449416
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Pathology Specimen Number (corresponding to cytogenetics specimen)
Description

SpecimenAccessionNumber

Data type

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25402
UMLS 2011AA Property
C1510755
Pathology specimen involved by malignancy?
Description

SpecimenMalignantInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C14143
UMLS 2011AA Property
C0205282
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Ccrr Module For Children's Oncology Group Cytogenetics Reporting Form [anhl01p1]
Description

Ccrr Module For Children's Oncology Group Cytogenetics Reporting Form [anhl01p1]

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CHILDREN'S ONCOLOGY GROUP CYTOGENETICS REPORTING FORM [ANHL01P1]
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Institution Name
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Person Completing Form
Item
Institution Personnel
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
PatientCOGIdentifierNumber
Item
Institution Patient Identifier
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)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)
PatientCOGIdentifierNumber
Item
Institution Patient Identifier
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)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)
Form Completion Date
Item
Today's date
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
DataEnteredDate
Item
Date worksheet entered into RDE
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C37949 (NCI Thesaurus Property)
C1521975 (UMLS 2011AA Property)
Item Group
Miscellaneous Patient Information
Item
Sex (Required field)
text
C25372 (NCI Thesaurus ValueDomain)
C0079399 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
CL.1
Code List
Sex (Required field)
CL Item
Male (Male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (Female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
If not at study entry, was the primary diagnosis specimen submitted to a cytogenetics laboratory (Required field)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
CL.2
Code List
If not at study entry, was the primary diagnosis specimen submitted to a cytogenetics laboratory (Required field)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not At Study Entry (Not at study entry)
Item
Specimen Time (Choose one)
text
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
CL.3
Code List
Specimen Time (Choose one)
CL Item
Primary diagnosis specimen (Primary diagnosis specimen)
CL Item
Staging (Staging)
CL Item
During therapy (During therapy)
CL Item
Relapse (Relapse)
CL Item
Other Specify (Other, specify below)
CL Item
Sample Or Specimen Collected After Patient Received Treatment For Cancer (Post-treatment)
CL Item
Sample Or Specimen Collected Before Patient Was Diagnosed With Cancer (Pre-diagnosis)
CL Item
Sample Or Specimen Collected Before Patient Received Treatment For Cancer (Pre-treatment)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
SpecimenCollectedPeriodSpecify
Item
please specify [specimen time] (Text)
text
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
SpecimenIdentifierNumber
Item
Cytogenetics Laboratory Specimen Number (Required field)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
SpecimenLaboratoryProcedureCollectionDate
Item
Data Specimen Collected (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C25294 (NCI Thesaurus Property-2)
C0022885 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
SpecimenLaboratoryReceivedDate
Item
Date Specimen Received in Cytogenetics Laboratory (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C37984 (NCI Thesaurus Property-2)
C0022877 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
Item
Specimen Type (Required field)
text
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.4
Code List
Specimen Type (Required field)
CL Item
Lymph Node (Surgical biopsy of lymph node)
C12745 (NCI Thesaurus)
C0024204 (UMLS 2011AA)
CL Item
Surgical biopsy of tumor (Surgical biopsy of tumor)
CL Item
Bone Marrow (Bone marrow aspirate)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Bone Marrow (Bone marrow biopsy)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Peripheral Blood (Peripheral blood)
C0229664 (NCI Metathesaurus)
CL Item
Body fluid (Body fluid)
CL Item
Fine needle aspirate (Fine needle aspirate)
CL Item
Other Specify (Other, specify below)
CL Item
Bone Biopsy (Bone biopsy)
CL Item
Cerebrospinal Fluid (Cerebrospinal fluid)
C12692 (NCI Thesaurus)
C0007806 (UMLS 2011AA)
CL Item
Peritoneal Fluid (Peritoneal fluid)
CL Item
Pleural Fluid (Pleural fluid)
C0225778 (NCI Metathesaurus)
CL Item
Soft Tissue Mass (Soft tissue mass)
C0457193 (NCI Metathesaurus)
SpecimenCellSourceSpecify
Item
please specify [specimen type] (Text)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C25683 (NCI Thesaurus Property-2)
C0449416 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
SpecimenAccessionNumber
Item
Pathology Specimen Number (corresponding to cytogenetics specimen)
float
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25402 (NCI Thesaurus Property)
C1510755 (UMLS 2011AA Property)
SpecimenMalignantInd-2
Item
Pathology specimen involved by malignancy?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C14143 (NCI Thesaurus Property)
C0205282 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
Item Group
Ccrr Module For Children's Oncology Group Cytogenetics Reporting Form [anhl01p1]
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