ID

43912

Beschrijving

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

Trefwoorden

Versies (4)
  1. 19-09-12 19-09-12 -
  2. 29-07-17 29-07-17 - Martin Dugas
  3. 29-07-17 29-07-17 - Martin Dugas
  4. 20-09-21 20-09-21 -
Geüploaded op

20 september 2021

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Leukemia Daunorubicin Cytarabine Oblimersen NCT00085124 CALGB

Engels

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 Formulieren  
Cytogenetics Referral Form
Beschrijving

Cytogenetics Referral Form

Alias
UMLS CUI-1
C0010802
CALGB Form
Beschrijving

CALGB Form

Datatype

text

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

CALGBTreatmentStudy#

Datatype

text

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

CALGBCompanionStudy#

Datatype

text

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

CALGBPatientID

Datatype

text

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

Data amended

Datatype

boolean

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

Patient'sName

Datatype

text

Alias
UMLS CUI [1]
C1299487
Patient Hospital Number
Beschrijving

PatientHospitalNumber

Datatype

text

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

MainMemberInstitution/Affiliate

Datatype

text

Alias
UMLS CUI [1]
C1301943
Participating Group
Beschrijving

ParticipatingGroupName

Datatype

text

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

ParticipatingGroupProtocolNo.

Datatype

text

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

ParticipatingGroupPatientID

Datatype

text

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

PatientGender

Datatype

text

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

HematopoieticDiagnosis

Datatype

text

Alias
UMLS CUI [1]
C0011900
Other, specify
Beschrijving

other,specifyinComments(diagnosis) (diagnosis)

Datatype

text

Alias
UMLS CUI [1]
C3845569
Date sample obtained
Beschrijving

Datesampleobtained

Datatype

date

Alias
UMLS CUI [1]
C0460065
other, specify
Beschrijving

SpecimenCollectionMethod,Other (sample obtained)

Datatype

text

Alias
UMLS CUI [1]
C3845569
other, specify
Beschrijving

other,specify (reason)

Datatype

text

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

Lab,Hematology,WBC (blood)

Datatype

float

Alias
UMLS CUI [1]
C0023508
% Blasts
Beschrijving

Lab,Hematology,Blasts,CellPercentage (blood)

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005767
%
% Blasts BM
Beschrijving

BoneMarrow,Blasts,CellPercentage (bone marrow)

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005953
%
Completed By
Beschrijving

CompletedBy (Print or Type Name)

Datatype

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Beschrijving

FormOriginalCompleteDate

Datatype

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
Beschrijving

PersonCompletingForm,Phone

Datatype

text

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

Sample type

Datatype

text

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

Ifbonemarrownotsubmitted,givereason

Datatype

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3640292
Terug naar het begin van de pagina

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial