ID

43186

Descrição

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

Link

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

Palavras-chave

Versões (4)
  1. 19/09/2012 19/09/2012 -
  2. 28/05/2015 28/05/2015 -
  3. 03/06/2015 03/06/2015 -
  4. 20/09/2021 20/09/2021 -
Transferido a

20 de setembro de 2021

DOI

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Licença

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

Inglês

No Instruction available.

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

ECOG clinical trial administrative data

ECOG Protocol No.
Descrição

ECOGProtocolNo.

Tipo de dados

text

ECOG Patient ID
Descrição

ECOGPatientID

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient?s Name
Descrição

Patient'sName

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Participating Group Patient ID
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

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

AmendedDataInd

Tipo de dados

boolean

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

Vital Status

Patient?s Vital Status
Descrição

Patient'sVitalStatus

Tipo de dados

text

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

DeathDate/LastContactDate

Tipo de dados

date

Cause of Death (if applicable)
Descrição

Causeofdeath

Tipo de dados

text

Transplant Conditioning Regimen
Descrição

Transplant Conditioning Regimen

Treatment Start Date
Descrição

TreatmentStartDate

Tipo de dados

date

Treatment End Date
Descrição

TreatmentEndDate

Tipo de dados

date

Agent Name
Descrição

AgentName

Tipo de dados

text

Agent Total Dose
Descrição

AgentTotalDose

Tipo de dados

float

Donor Information
Descrição

Donor Information

Relationship to recipient
Descrição

Relationshiptorecipient

Tipo de dados

text

Donor gender
Descrição

Donorgender

Tipo de dados

text

CMV status
Descrição

CMVstatus

Tipo de dados

text

EBV status
Descrição

EBVstatus

Tipo de dados

text

Donor birth date
Descrição

Donorbirthdate

Tipo de dados

text

Allogeneic Transplant
Descrição

Allogeneic Transplant

Did patient receive protocol transplant?
Descrição

ProtocolTransplantInd

Tipo de dados

boolean

Date of last peripheral blood stem cell infusion
Descrição

Dateoflastperipheralbloodstemcellinfusion

Tipo de dados

text

Total no. of CD34+ cells infused
Descrição

Totalno.ofCD34+cellsinfused

Tipo de dados

text

Transfusions
Descrição

Transfusions

Number of post-transplant platelet transfusions
Descrição

Numberofpost-transplantplatelettransfusions

Tipo de dados

text

Date of most recent platelet transfusion
Descrição

PlateletTransfusionReceivedMostRecentDate

Tipo de dados

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
Descrição

Numberofpost-transplantRBCtransfusions

Tipo de dados

text

Date of most recent RBC transfusion
Descrição

PackedRedBloodCellTransfusionReceivedMostRecentDate

Tipo de dados

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)
Descrição

OffTreatmentReason

Tipo de dados

text

Specify complicating disease (reason treatment ended)
Descrição

OffTreatmentReason,ComplicatingDisease

Tipo de dados

text

Specify other Reasons (reason treatment ended)
Descrição

OffTreatmentReason,Other

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

Investigator Signature
Descrição

InvestigatorSignature

Tipo de dados

text

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

InvestigatorSignatureDate

Tipo de dados

date

Ccrr Module For Treatment Form - Allogeneic Transplant
Descrição

Ccrr Module For Treatment Form - Allogeneic Transplant

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: Treatment Form - Allogeneic Transplant
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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