ID

43912

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2017-07-29 2017-07-29 - Martin Dugas
  3. 2017-07-29 2017-07-29 - Martin Dugas
  4. 2021-09-20 2021-09-20 -
Uppladdad den

20 september 2021

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0

Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Leukemia Daunorubicin Cytarabine Oblimersen NCT00085124 CALGB

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.

Cytogenetics Referral Form
Beskrivning

Cytogenetics Referral Form

Alias
UMLS CUI-1
C0010802
CALGB Form
Beskrivning

CALGB Form

Datatyp

text

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

CALGBTreatmentStudy#

Datatyp

text

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

CALGBCompanionStudy#

Datatyp

text

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

CALGBPatientID

Datatyp

text

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

Data amended

Datatyp

boolean

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

Patient'sName

Datatyp

text

Alias
UMLS CUI [1]
C1299487
Patient Hospital Number
Beskrivning

PatientHospitalNumber

Datatyp

text

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

MainMemberInstitution/Affiliate

Datatyp

text

Alias
UMLS CUI [1]
C1301943
Participating Group
Beskrivning

ParticipatingGroupName

Datatyp

text

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

ParticipatingGroupProtocolNo.

Datatyp

text

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

ParticipatingGroupPatientID

Datatyp

text

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

PatientGender

Datatyp

text

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

HematopoieticDiagnosis

Datatyp

text

Alias
UMLS CUI [1]
C0011900
Other, specify
Beskrivning

other,specifyinComments(diagnosis) (diagnosis)

Datatyp

text

Alias
UMLS CUI [1]
C3845569
Date sample obtained
Beskrivning

Datesampleobtained

Datatyp

date

Alias
UMLS CUI [1]
C0460065
other, specify
Beskrivning

SpecimenCollectionMethod,Other (sample obtained)

Datatyp

text

Alias
UMLS CUI [1]
C3845569
other, specify
Beskrivning

other,specify (reason)

Datatyp

text

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

Lab,Hematology,WBC (blood)

Datatyp

float

Alias
UMLS CUI [1]
C0023508
% Blasts
Beskrivning

Lab,Hematology,Blasts,CellPercentage (blood)

Datatyp

float

Måttenheter
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005767
%
% Blasts BM
Beskrivning

BoneMarrow,Blasts,CellPercentage (bone marrow)

Datatyp

float

Måttenheter
  • %
Alias
UMLS CUI [1,1]
C0587348
UMLS CUI [1,2]
C0005953
%
Completed By
Beskrivning

CompletedBy (Print or Type Name)

Datatyp

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Beskrivning

FormOriginalCompleteDate

Datatyp

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
Beskrivning

PersonCompletingForm,Phone

Datatyp

text

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

Sample type

Datatyp

text

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

Ifbonemarrownotsubmitted,givereason

Datatyp

text

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

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.

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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])
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])
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])
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])
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)

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

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