ID

43193

Description

E1900 Material Submission Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia NCT00049517 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E0B4-B257-2F80-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E0B4-B257-2F80-E034-0003BA0B1A09

Keywords

Versions (4)
  1. 5/25/12 5/25/12 -
  2. 2/4/15 2/4/15 - Martin Dugas
  3. 7/9/15 7/9/15 - Martin Dugas
  4. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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AML Material Submission Form Pathology NCT00049517

English

No Instruction available.

1 forms  
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Header
Description

Header

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C1512162
ECOG Patient ID
Description

ECOGPatientID

Data type

text

Alias
UMLS CUI-1
C2348585
UMLS CUI-2
C1512162
Registration Step
Description

RegistrationStep

Data type

text

Alias
UMLS CUI-1
C1514821
Patient's Name
Description

Patient'sName

Data type

text

Alias
UMLS CUI-1
C1299487
Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C2347449
Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Alias
UMLS CUI-1
C2348585
UMLS CUI-2
C2347449
Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Alias
UMLS CUI-1
C1301943
Peripheral and Marrow Blast Percentage
Description

PeripheralandMarrowBlastPercentage

Data type

float

Measurement units
  • %
Alias
UMLS CUI-1
C0942416
%
Sample No.
Description

SampleNo.

Data type

text

Alias
UMLS CUI-1
C0237753
UMLS CUI-2
C0370003
Investigator signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
UMLS CUI-1
C2346576
Investigator Signature Date
Description

InvestigatorSignatureDate

Data type

date

Alias
UMLS CUI-1
C2346576
UMLS CUI-2
C0011008
Comments
Description

Comments

Data type

text

Alias
UMLS CUI-1
C0947611
Completed By Submitting Institutions
Description

Completed By Submitting Institutions

Date material(s) sent to central laboratory
Description

SpecimenCentralLaboratorySubmissionDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C37984
NCI Metathesaurus Property
C0205099
NCI Thesaurus Property-2
C25694
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1515022
UMLS CUI-2
C0011008
Shipped to
Description

SpecimenLaboratoryReceivedLocationName

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25341
NCI Thesaurus Property-2
C25639
NCI Thesaurus Property-3
C37984
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C0022877
Date Materials collected
Description

SpecimenCollectionDate

Data type

date

Alias
UMLS CUI-1
C1317250
Tissue/material type
Description

SpecimenSubmittedType

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C2347029
Type of collection/stain/process
Description

Typeofcollection/stain/process

Data type

text

Timing of material collection
Description

SpecimenCollectionPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C25616
NCI Thesaurus Property-2
C25453
NCI Thesaurus ObjectClass
C19157
UMLS CUI-1
C2347804
number of specimens submitted
Description

numberofspecimenssubmitted

Data type

integer

Alias
UMLS CUI-1
C0750480
UMLS CUI-2
C0370003
UMLS CUI-3
C1515023
Leukemia MDS Diagnosis
Description

Leukemia MDS Classification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C3161
NCI Thesaurus Property
C25161
UMLS CUI-1
C0023418
UMLS CUI-2
C3463824
UMLS CUI-3
C0008902
Absolute blast count
Description

Lab,Hematology,BlastCount

Data type

float

Alias
UMLS CUI-1
C1982687
Institution contact name
Description

ContactPersonatInstitution

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass-2
C25461
UMLS CUI-1
C0018704
UMLS CUI-2
C0337611
Principal Investigator name
Description

RegisteredInvestigator

Data type

text

Alias
UMLS CUI-1
C1521895
Institution contact phone number
Description

InstitutionContactTelephoneNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus Property
C25395
NCI Thesaurus ObjectClass-2
C25461
UMLS CUI-1
C0039457
UMLS CUI-2
C0337611
Institution contact fax number
Description

InstitutionContactFaxNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ObjectClass-2
C25461
NCI Thesaurus Property
C25210
UMLS CUI-1
C0337611
UMLS CUI-2
C0085205
Completed By Central Lab
Description

Completed By Central Lab

Date materials received at central lab
Description

SpecimenReceivedDate

Data type

date

Alias
UMLS CUI-1
C0011008
UMLS CUI-2
C2585542
Condition of material(s)
Description

SpecimenCondition

Data type

text

Alias
UMLS CUI-1
C1547869
Aliquots of sample made
Description

Aliquotsofsamplemade

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1510844
Central Laboratory contact name
Description

CentralLaboratoryContactPersonName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C37984
NCI Metathesaurus ObjectClass
C0205099
NCI Thesaurus ObjectClass-3
C25461
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C0337611
UMLS CUI-2
C0022877
contact phone number
Description

CentralLaboratoryContactTelephoneNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C25461
NCI Thesaurus ObjectClass-2
C64207
NCI Thesaurus Property
C25395
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ValueDomain-2
C25395
UMLS CUI-1
C0039457
UMLS CUI-2
C1880016
Contact fax number
Description

CentralLaboratoryContactFaxNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25461
NCI Thesaurus ObjectClass-2
C64207
NCI Thesaurus Property
C25210
UMLS CUI-1
C0085205
UMLS CUI-2
C1880016
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
ECOG Protocol Number
Item
ECOG Protocol No.
text
C3274381 (UMLS CUI-1)
C1512162 (UMLS CUI-2)
ECOG Patient ID
Item
ECOG Patient ID
text
C2348585 (UMLS CUI-1)
C1512162 (UMLS CUI-2)
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI-1)
Patient name
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
Participating Group Protocol Number
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI-1)
C2347449 (UMLS CUI-2)
Participating Group Patient ID
Item
Participating Group Patient ID
text
C2348585 (UMLS CUI-1)
C2347449 (UMLS CUI-2)
Institution
Item
Institution/Affiliate
text
C1301943 (UMLS CUI-1)
Blast percentage
Item
Peripheral and Marrow Blast Percentage
float
C0942416 (UMLS CUI-1)
Sample number
Item
Sample No.
text
C0237753 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
Investigator signature
Item
Investigator signature
text
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
Investigator Signature Date
Item
Investigator Signature Date
date
C2346576 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Comments
Item
Comments
text
C0947611 (UMLS CUI-1)
Item Group
Completed By Submitting Institutions
Submission date
Item
Date material(s) sent to central laboratory
date
C19157 (NCI Thesaurus ObjectClass)
C37984 (NCI Thesaurus Property)
C0205099 (NCI Metathesaurus Property)
C25694 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C1515022 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Item
Shipped to
text
C19157 (NCI Thesaurus ObjectClass)
C25341 (NCI Thesaurus Property)
C25639 (NCI Thesaurus Property-2)
C37984 (NCI Thesaurus Property-3)
C25191 (NCI Thesaurus ValueDomain)
C0022877 (UMLS CUI-1)
CL.1
Code List
Shipped to
CL Item
Leukemia Immunophenotyping Reference Library (Leukemia Immunophenotyping Reference Library)
CL Item
Ecog Cytogenetics Laboratory (ECOG Cytogenetics Laboratory)
CL Item
Other Central Laboratory (Other Central Laboratory)
Collection Date
Item
Date Materials collected
date
C1317250 (UMLS CUI-1)
Item
Tissue/material type
integer
C25284 (NCI Thesaurus ValueDomain)
C2347029 (UMLS CUI-1)
CL.3
Code List
Tissue/material type
CL Item
Other (0)
CL Item
Peripheral Blood (1)
CL Item
Bone Marrow Aspirate (2)
CL Item
Bone Marrow Biopsy (3)
CL Item
Karyotype (4)
CL Item
Peripheral Blood Stem Cell Harvest (5)
Item
Type of collection/stain/process
text
CL.4
Code List
Type of collection/stain/process
CL Item
Green Top (heparinized) (green top (heparinized))
CL Item
Red Top (red top)
CL Item
Slide, Unstained, Charged (slide, unstained, charged)
CL Item
Slide/air Dried Smear (slide/air dried smear)
CL Item
Karyotype (karyotype)
C25215 (NCI Thesaurus)
C1261273 (UMLS 2011AA)
CL Item
Stem Cell Harvest (stem cell harvest)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Timing of material collection
text
C25284 (NCI Thesaurus ValueDomain)
C25616 (NCI Thesaurus Property)
C25453 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus ObjectClass)
C2347804 (UMLS CUI-1)
CL.5
Code List
Timing of material collection
CL Item
Baseline/pretreatment (baseline/pretreatment)
CL Item
Pre-transplant Remission Prior To Consolidation (pre-transplant remission prior to consolidation)
CL Item
Pre-transplant , Post-consolidation Chemotherapy (pre-transplant , post-consolidation chemotherapy)
CL Item
1 Mo. Post-transplant (1 mo. Post-transplant)
CL Item
6 Mos. Post-transplant (6 mos. Post-transplant)
CL Item
12 Mos. Post-transplant (12 mos. Post-transplant)
CL Item
Stem Cell Harvest (stem cell harvest)
CL Item
Relapse (relapse)
C18265 (NCI Thesaurus)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Number of specimens submitted
Item
number of specimens submitted
integer
C0750480 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
C1515023 (UMLS CUI-3)
Item
Leukemia MDS Diagnosis
text
C25372 (NCI Thesaurus ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C0023418 (UMLS CUI-1)
C3463824 (UMLS CUI-2)
C0008902 (UMLS CUI-3)
CL.6
Code List
Leukemia MDS Diagnosis
CL Item
AML, Not Otherwise Specified (nos) (acute myeloid leukemia)
CL Item
ALL, Not Otherwise Specified (nos) (acute lymphocytic leukemia)
CL Item
Chronic Lymphocytic Leukemia (CLL) (chronic lymphocytic leukemia)
CL Item
Chronic Myelogenous Leukemia (CML), Chronic Phase (CML-chronic phase)
CL Item
Myelodysplastic Syndrome (MDS) Nos (MDS-myelodysplastic syndrome)
CL Item
Disease Classified As Specified Other Leukemia (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
CL Item
Chronic Myelogenous Leukemia, (CML), Blast Crisis (CML-blast cells)
Blast count
Item
Absolute blast count
float
C1982687 (UMLS CUI-1)
Institution contact name
Item
Institution contact name
text
C21541 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25461 (NCI Thesaurus ObjectClass-2)
C0018704 (UMLS CUI-1)
C0337611 (UMLS CUI-2)
Principal Investigator name
Item
Principal Investigator name
text
C1521895 (UMLS CUI-1)
Phone contact person
Item
Institution contact phone number
text
C25337 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25395 (NCI Thesaurus Property)
C25461 (NCI Thesaurus ObjectClass-2)
C0039457 (UMLS CUI-1)
C0337611 (UMLS CUI-2)
Fax number contact person
Item
Institution contact fax number
text
C25337 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25461 (NCI Thesaurus ObjectClass-2)
C25210 (NCI Thesaurus Property)
C0337611 (UMLS CUI-1)
C0085205 (UMLS CUI-2)
Item Group
Completed By Central Lab
Date Specimen Received
Item
Date materials received at central lab
date
C0011008 (UMLS CUI-1)
C2585542 (UMLS CUI-2)
Item
Condition of material(s)
text
C1547869 (UMLS CUI-1)
CL.8
Code List
Condition of material(s)
CL Item
Damaged Or Unusable (not usable as received)
CL Item
Useable (usable as received)
Aliquots
Item
Aliquots of sample made
boolean
C25180 (NCI Thesaurus ValueDomain)
C1510844 (UMLS CUI-1)
Contact name Laboratory
Item
Central Laboratory contact name
text
C25190 (NCI Thesaurus ObjectClass)
C37984 (NCI Thesaurus ObjectClass-2)
C0205099 (NCI Metathesaurus ObjectClass)
C25461 (NCI Thesaurus ObjectClass-3)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C0337611 (UMLS CUI-1)
C0022877 (UMLS CUI-2)
Phone number Central laboratory
Item
contact phone number
text
C25461 (NCI Thesaurus ObjectClass)
C64207 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus ValueDomain-2)
C0039457 (UMLS CUI-1)
C1880016 (UMLS CUI-2)
Fax number Central laboratory
Item
Contact fax number
text
C25337 (NCI Thesaurus ValueDomain)
C25461 (NCI Thesaurus ObjectClass)
C64207 (NCI Thesaurus ObjectClass-2)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS CUI-1)
C1880016 (UMLS CUI-2)
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