ID

43186

Descrizione

Treatment Form - Allogeneic Transplant NCT00049517 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=A727E9EC-B147-2F86-E034-0003BA0B1A09

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E9EC-B147-2F86-E034-0003BA0B1A09

Keywords

versioni (4)
  1. 19/09/12 19/09/12 -
  2. 28/05/15 28/05/15 -
  3. 03/06/15 03/06/15 -
  4. 20/09/21 20/09/21 -
Caricato su

20 settembre 2021

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Treatment Form - Allogeneic Transplant NCT00049517

Inglese

No Instruction available.

1 moduli  
  1. StudyEvent: Treatment Form - Allogeneic Transplant
    1. No Instruction available.
ECOG clinical trial administrative data
Descrizione

ECOG clinical trial administrative data

ECOG Protocol No.
Descrizione

ECOGProtocolNo.

Tipo di dati

text

ECOG Patient ID
Descrizione

ECOGPatientID

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient?s Name
Descrizione

Patient'sName

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Participating Group Patient ID
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

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

AmendedDataInd

Tipo di dati

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Vital Status
Descrizione

Vital Status

Patient?s Vital Status
Descrizione

Patient'sVitalStatus

Tipo di dati

text

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

DeathDate/LastContactDate

Tipo di dati

date

Cause of Death (if applicable)
Descrizione

Causeofdeath

Tipo di dati

text

Transplant Conditioning Regimen
Descrizione

Transplant Conditioning Regimen

Treatment Start Date
Descrizione

TreatmentStartDate

Tipo di dati

date

Treatment End Date
Descrizione

TreatmentEndDate

Tipo di dati

date

Agent Name
Descrizione

AgentName

Tipo di dati

text

Agent Total Dose
Descrizione

AgentTotalDose

Tipo di dati

float

Donor Information
Descrizione

Donor Information

Relationship to recipient
Descrizione

Relationshiptorecipient

Tipo di dati

text

Donor gender
Descrizione

Donorgender

Tipo di dati

text

CMV status
Descrizione

CMVstatus

Tipo di dati

text

EBV status
Descrizione

EBVstatus

Tipo di dati

text

Donor birth date
Descrizione

Donorbirthdate

Tipo di dati

text

Allogeneic Transplant
Descrizione

Allogeneic Transplant

Did patient receive protocol transplant?
Descrizione

ProtocolTransplantInd

Tipo di dati

boolean

Date of last peripheral blood stem cell infusion
Descrizione

Dateoflastperipheralbloodstemcellinfusion

Tipo di dati

text

Total no. of CD34+ cells infused
Descrizione

Totalno.ofCD34+cellsinfused

Tipo di dati

text

Transfusions
Descrizione

Transfusions

Number of post-transplant platelet transfusions
Descrizione

Numberofpost-transplantplatelettransfusions

Tipo di dati

text

Date of most recent platelet transfusion
Descrizione

PlateletTransfusionReceivedMostRecentDate

Tipo di dati

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-2
C25577
UMLS 2011AA ValueDomain-2
C1513491
Number of post-transplant RBC transfusions
Descrizione

Numberofpost-transplantRBCtransfusions

Tipo di dati

text

Date of most recent RBC transfusion
Descrizione

PackedRedBloodCellTransfusionReceivedMostRecentDate

Tipo di dati

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-2
C25577
UMLS 2011AA ValueDomain-2
C1513491
Reason Treatment Ended (Choose one)
Descrizione

OffTreatmentReason

Tipo di dati

text

Specify complicating disease (reason treatment ended)
Descrizione

OffTreatmentReason,ComplicatingDisease

Tipo di dati

text

Specify other Reasons (reason treatment ended)
Descrizione

OffTreatmentReason,Other

Tipo di dati

text

Comments
Descrizione

Comments

Comments
Descrizione

Comments

Tipo di dati

text

Investigator Signature
Descrizione

InvestigatorSignature

Tipo di dati

text

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

InvestigatorSignatureDate

Tipo di dati

date

Ccrr Module For Treatment Form - Allogeneic Transplant
Descrizione

Ccrr Module For Treatment Form - Allogeneic Transplant

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Similar models

No Instruction available.

1 moduli
  1. StudyEvent: Treatment Form - Allogeneic Transplant
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
ECOG clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
AmendedDataInd
Item
Are data amended? (If yes, please circle amended items in red)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
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
Cause of Death (if applicable)
text
CL.3
Code List
Cause of Death (if applicable)
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 (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Transplant Conditioning Regimen
TreatmentStartDate
Item
Treatment Start Date
date
TreatmentEndDate
Item
Treatment End Date
date
AgentName
Item
Agent Name
text
AgentTotalDose
Item
Agent Total Dose
float
Item Group
Donor Information
Item
Relationship to recipient
text
CL.4
Code List
Relationship to recipient
CL Item
Sibling (sibling)
C25204 (NCI Thesaurus)
C0037047 (UMLS 2011AA)
CL Item
Other Family Member (other family member)
CL Item
Unrelated (unrelated)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
Item
Donor gender
text
CL.5
Code List
Donor gender
CL Item
Male (male)
C20197 (NCI Thesaurus)
C0086582 (UMLS 2011AA)
CL Item
Female (female)
C16576 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Item
CMV status
text
CL.6
Code List
CMV status
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
EBV status
text
CL.7
Code List
EBV status
CL Item
Negative (negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Donorbirthdate
Item
Donor birth date
text
Item Group
Allogeneic Transplant
ProtocolTransplantInd
Item
Did patient receive protocol transplant?
boolean
Dateoflastperipheralbloodstemcellinfusion
Item
Date of last peripheral blood stem cell infusion
text
Totalno.ofCD34+cellsinfused
Item
Total no. of CD34+ cells infused
text
Item Group
Transfusions
Numberofpost-transplantplatelettransfusions
Item
Number of post-transplant platelet transfusions
text
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-2)
C1513491 (UMLS 2011AA ValueDomain-2)
Numberofpost-transplantRBCtransfusions
Item
Number of post-transplant RBC transfusions
text
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-2)
C1513491 (UMLS 2011AA ValueDomain-2)
Item
Reason Treatment Ended (Choose one)
text
CL.9
Code List
Reason Treatment Ended (Choose one)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
OffTreatmentReason,ComplicatingDisease
Item
Specify complicating disease (reason treatment ended)
text
OffTreatmentReason,Other
Item
Specify other Reasons (reason treatment ended)
text
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 Treatment Form - Allogeneic Transplant
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