ID

43912

Description

CALGB: CYTOGENETICS REFERRAL FORM NCT00085124 Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229EF62-6ADF-5120-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229EF62-6ADF-5120-E034-0003BA12F5E7

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 7/29/17 7/29/17 - Martin Dugas
  3. 7/29/17 7/29/17 - Martin Dugas
  4. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

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License

Creative Commons BY-NC 3.0
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Leukemia Daunorubicin Cytarabine Oblimersen NCT00085124 CALGB

English

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms  
Cytogenetics Referral Form
Description

Cytogenetics Referral Form

Alias
UMLS CUI-1
C0010802
CALGB Form
Description

CALGB Form

Data type

text

Alias
UMLS CUI-1
C3262252
UMLS CUI-2
C1516238
CALGB Treatment Study #
Description

CALGBTreatmentStudy#

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1516238
CALGB Companion Study #
Description

CALGBCompanionStudy#

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1516238
CALGB Patient ID
Description

CALGBPatientID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C1516238
Amended Data?
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI [1,1]
C1511726
UMLS CUI [1,2]
C1691222
Patient's Name
Description

Patient'sName

Data type

text

Alias
UMLS CUI [1]
C1299487
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Alias
UMLS CUI [1]
C0806432
Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Data type

text

Alias
UMLS CUI [1]
C1301943
Participating Group
Description

ParticipatingGroupName

Data type

text

Alias
UMLS CUI [1]
C2347449
Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Alias
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C2347449
Participating Group Patient No.
Description

ParticipatingGroupPatientID

Data type

text

Alias
UMLS CUI [1,1]
C2348585
UMLS CUI [1,2]
C2347449
Sex
Description

PatientGender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17357
UMLS CUI [1]
C0079399
Diagnosis
Description

HematopoieticDiagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Other, specify
Description

other,specifyinComments(diagnosis) (diagnosis)

Data type

text

Alias
UMLS CUI [1]
C3845569
Date sample obtained
Description

Datesampleobtained

Data type

date

Alias
UMLS CUI [1]
C0460065
other, specify
Description

SpecimenCollectionMethod,Other (sample obtained)

Data type

text

Alias
UMLS CUI [1]
C3845569
other, specify
Description

other,specify (reason)

Data type

text

Alias
NCI Thesaurus ObjectClass
C25179
NCI Thesaurus Property
C25365
UMLS CUI [1]
C3845569
WBC
Description

Lab,Hematology,WBC (blood)

Data type

float

Alias
UMLS CUI [1]
C0023508
% Blasts
Description

Lab,Hematology,Blasts,CellPercentage (blood)

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005767
%
% Blasts BM
Description

BoneMarrow,Blasts,CellPercentage (bone marrow)

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005953
%
Completed By
Description

CompletedBy (Print or Type Name)

Data type

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Description

FormOriginalCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1549507
Telephone Number
Description

PersonCompletingForm,Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI [1]
C1515258
Sample type
Description

Sample type

Data type

text

Alias
UMLS CUI [1]
C2347029
If bone marrow not submitted, give reason
Description

Ifbonemarrownotsubmitted,givereason

Data type

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3640292
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Similar models

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Cytogenetics Referral Form
C0010802 (UMLS CUI-1)
CALGB Form
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGB Study Number
Item
CALGB Treatment Study #
text
C3274381 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
CALGB Companion Study Number
Item
CALGB Companion Study #
text
C3274381 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
CALGB Patient ID
Item
CALGB Patient ID
text
C2348585 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
Amended Data
Item
Amended Data?
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI [1,1])
C1691222 (UMLS CUI [1,2])
Patient Name
Item
Patient's Name
text
C1299487 (UMLS CUI [1])
Hospital Number
Item
Patient Hospital Number
text
C0806432 (UMLS CUI [1])
Main Member Institution/Adjunct
Item
Main Member Institution/Adjunct
text
C1301943 (UMLS CUI [1])
Participating Group
Item
Participating Group
text
C2347449 (UMLS CUI [1])
Participating Group Protocol No.
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Participating Group Patient No.
Item
Participating Group Patient No.
text
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Item
Sex
text
C25372 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI [1])
CL.2
Code List
Sex
CL Item
Male (male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
CL.3
Code List
Diagnosis
CL Item
ALL (ALL)
C0023449 (UMLS CUI-1)
(Comment:en)
CL Item
AML (AML)
C0023467 (UMLS CUI-1)
(Comment:en)
CL Item
MDS (MDS)
C3463824 (UMLS CUI-1)
(Comment:en)
CL Item
CML (CML)
C0023473 (UMLS CUI-1)
(Comment:en)
CL Item
Other, specify (Other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)
Other, specify
Item
Other, specify
text
C3845569 (UMLS CUI [1])
Date sample received
Item
Date sample obtained
date
C0460065 (UMLS CUI [1])
other, specify
Item
other, specify
text
C3845569 (UMLS CUI [1])
other, specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C3845569 (UMLS CUI [1])
WBC
Item
WBC
float
C0023508 (UMLS CUI [1])
Percentage Blasts, blood
Item
% Blasts
float
C0587348 (UMLS CUI [1,1])
C0005767 (UMLS CUI [1,2])
Percentage Blasts, bone marrow
Item
% Blasts BM
float
C0587348 (UMLS CUI [1,1])
C0005953 (UMLS CUI [1,2])
Completed By
Item
Completed By
text
C1550483 (UMLS CUI [1])
Date Completed
Item
Date Completed
date
C25164 (NCI Thesaurus ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI [1])
Telephone Number
Item
Telephone Number
text
C25704 (NCI Thesaurus ValueDomain)
C1515258 (UMLS CUI [1])
Item
Sample type
text
C2347029 (UMLS CUI [1])
CL.4
Code List
Sample type
CL Item
sample obtained (sample obtained)
C1277697 (UMLS CUI-1)
(Comment:en)
CL Item
bone marrow aspirate (bone marrow aspirate)
C1271729 (UMLS CUI-1)
(Comment:en)
CL Item
blood (blood)
C0005767 (UMLS CUI-1)
(Comment:en)
CL Item
other, specify (other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)
Item
If bone marrow not submitted, give reason
text
C0566251 (UMLS CUI [1,1])
C3640292 (UMLS CUI [1,2])
CL.5
Code List
If bone marrow not submitted, give reason
CL Item
inaspirable (inaspirable)
C0398523 (UMLS CUI-1)
C1272705 (UMLS CUI-2)
(Comment:en)
CL Item
other, specify (other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)
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