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ACNS0122 Eligibility Worksheet Neoadjuvant Chemotherapy With or Without Second-Look Surgery Followed by Radiation Therapy With or Without Peripheral Stem Cell Transplantation in Treating Patients With Intracranial Germ Cell Tumors Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD908887-2F0D-1578-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BD908887-2F0D-1578-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 21-06-15 21-06-15 -
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26 augustus 2012

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Creative Commons BY-NC 3.0 Legacy
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    Brain and Central Nervous System Tumors NCT00047320 Eligibility - ACNS0122 Eligibility Worksheet - 2169023v3.0

    Engels

    No Instruction available.

    1 Formulieren  
    1. StudyEvent: ACNS0122 Eligibility Worksheet
      1. No Instruction available.
    Unnamed1
    Beschrijving

    Unnamed1

    Name
    Beschrijving

    InstitutionName

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Study Number
    Beschrijving

    ProtocolCOGIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Study Number
    Beschrijving

    ProtocolCOGIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    COG Number
    Beschrijving

    PatientCOGIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C39353
    UMLS 2011AA Property
    C1516477
    Patient Name
    Beschrijving

    PatientName

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Today's date
    Beschrijving

    FormOriginalCompleteDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property
    C25604
    UMLS 2011AA Property
    C0205313
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Date worksheet entered into RDE
    Beschrijving

    DataEnteredDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C37949
    UMLS 2011AA Property
    C1521975
    Unnamed2
    Beschrijving

    Unnamed2

    Was the patient greater than 3 years of age and less than 25 years of age at diagnosis?
    Beschrijving

    PatientRequiredAgeInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25652
    UMLS 2011AA Property
    C1514873
    NCI Thesaurus Property
    C25150
    UMLS 2011AA Property
    C0001779
    Did the patient have histologic verification of one of the following? -Endodermal sinus tumor (yolk sac tumor); -Embryonal carcinoma; -Choriocarcinoma; -Immature teratoma; -Teratoma with malignant transformation; -Mixed germ cell tumor
    Beschrijving

    DiseaseHistologicDiagnosisInd

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    Did the patient have any histologically confirmed germ cell tumor with elevation of serum/CSF beta HCG >50 IU/dl or any elevation of CSF alpha fetoprotein >10IU/L
    Beschrijving

    GermCellTumorEligibilityInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    Did the patient have histologically unconfirmed pineal and/or suprasellar tumors with serum/CSF tumor markers of beta>50 IU/dl or any elevation of alpha fetoprotein >10 IU/L?
    Beschrijving

    BrainTumorEligibilityInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    Was surgery performed?
    Beschrijving

    PriorSurgeryPerformedInd-3

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    was a cranial MRI with gadolinium obtained prior to induction or pre-operative and post-operative? (If yes,)
    Beschrijving

    CranialMRIPerformedInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    No
    Beschrijving

    SpinalMRIPerformedInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    No
    Beschrijving

    SpinalMRIPerformedInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    No
    Beschrijving

    SpinalMRIPerformedInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Will the start of treatment begin within 31 days of initial diagnosis and within 7 days from study enrollment?
    Beschrijving

    TreatmentRequiredBeginDateInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Karnofsky Performance Score
    Beschrijving

    KarnofskyPerformanceStatusScale

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus ObjectClass
    C28013
    UMLS 2011AA ObjectClass
    C0206065
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Lansky Play Score
    Beschrijving

    LanskyPerformanceStatusScale

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus ObjectClass
    C25361
    UMLS 2011AA ObjectClass
    C0597198
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Does the patient have a life expectancy of more than or equal to 2 months?
    Beschrijving

    PatientLifeExpectancyEligibilityDeterminationInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C37987
    UMLS 2011AA Property
    C0376558
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    NCI Thesaurus Property
    C25359
    UMLS 2011AA Property
    C0679138
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Does the patient have a life expectancy of more than or equal to 2 months?
    Beschrijving

    PatientLifeExpectancyEligibilityDeterminationInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C37987
    UMLS 2011AA Property
    C0376558
    NCI Thesaurus Property
    C25171
    UMLS 2011AA Property
    C0013893
    NCI Thesaurus Property
    C25359
    UMLS 2011AA Property
    C0679138
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Has patient received prior treatment other than surgery and corticosteriods?
    Beschrijving

    CancerPriorTreatmentInd-3

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus Property
    C15368
    Did patient receive growth hormone therapy?
    Beschrijving

    PriorGrowthHormoneTherapyInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C15368
    Does the patient have adequate bone marrow function?
    Beschrijving

    PatientBoneMarrowFunctionRequiredInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25518
    UMLS 2011AA Property
    C0542341
    Does the patient have adequate renal function?
    Beschrijving

    PatientRenalFunctionRequiredInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25518
    UMLS 2011AA Property
    C0542341
    Does the patient have adequate Central Nervous System function?
    Beschrijving

    PatientCNSFunctionRequiredInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25518
    UMLS 2011AA Property
    C0542341
    is the patient pregnant and/or breastfeeding? (If female,)
    Beschrijving

    PatientPregnancyInd

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25742
    UMLS 2011AA Property
    C0032961
    Has the patient and/or their parents or legal guardians signed a written informed consent?
    Beschrijving

    InformedConsentFormSignedDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Have all institutional, FDA, and NCI requirements for human studies been met?
    Beschrijving

    StudyCompleteRequirementsInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C15206
    UMLS 2011AA ObjectClass
    C0008972
    NCI Thesaurus Property
    C38015
    Ccrr Module For Acns0122 Eligibility Worksheet
    Beschrijving

    Ccrr Module For Acns0122 Eligibility Worksheet

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    1 Formulieren
    1. StudyEvent: ACNS0122 Eligibility Worksheet
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Unnamed1
    InstitutionName
    Item
    Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolCOGIdentifierNumber
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolCOGIdentifierNumber
    Item
    Study Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientCOGIdentifierNumber
    Item
    COG Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C39353 (NCI Thesaurus Property)
    C1516477 (UMLS 2011AA Property)
    PatientName
    Item
    Patient Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    FormOriginalCompleteDate
    Item
    Today's date
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25604 (NCI Thesaurus Property)
    C0205313 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    DataEnteredDate
    Item
    Date worksheet entered into RDE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C37949 (NCI Thesaurus Property)
    C1521975 (UMLS 2011AA Property)
    Item Group
    Unnamed2
    Item
    Was the patient greater than 3 years of age and less than 25 years of age at diagnosis?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25652 (NCI Thesaurus Property)
    C1514873 (UMLS 2011AA Property)
    C25150 (NCI Thesaurus Property)
    C0001779 (UMLS 2011AA Property)
    CL.1
    Code List
    Was the patient greater than 3 years of age and less than 25 years of age at diagnosis?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Did the patient have histologic verification of one of the following? -Endodermal sinus tumor (yolk sac tumor); -Embryonal carcinoma; -Choriocarcinoma; -Immature teratoma; -Teratoma with malignant transformation; -Mixed germ cell tumor
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    CL.2
    Code List
    Did the patient have histologic verification of one of the following? -Endodermal sinus tumor (yolk sac tumor); -Embryonal carcinoma; -Choriocarcinoma; -Immature teratoma; -Teratoma with malignant transformation; -Mixed germ cell tumor
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Did the patient have any histologically confirmed germ cell tumor with elevation of serum/CSF beta HCG >50 IU/dl or any elevation of CSF alpha fetoprotein >10IU/L
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    CL.3
    Code List
    Did the patient have any histologically confirmed germ cell tumor with elevation of serum/CSF beta HCG >50 IU/dl or any elevation of CSF alpha fetoprotein >10IU/L
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Did the patient have histologically unconfirmed pineal and/or suprasellar tumors with serum/CSF tumor markers of beta>50 IU/dl or any elevation of alpha fetoprotein >10 IU/L?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    CL.4
    Code List
    Did the patient have histologically unconfirmed pineal and/or suprasellar tumors with serum/CSF tumor markers of beta>50 IU/dl or any elevation of alpha fetoprotein >10 IU/L?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Was surgery performed?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    CL.6
    Code List
    Was surgery performed?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    was a cranial MRI with gadolinium obtained prior to induction or pre-operative and post-operative? (If yes,)
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    CL.7
    Code List
    was a cranial MRI with gadolinium obtained prior to induction or pre-operative and post-operative? (If yes,)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    SpinalMRIPerformedInd-2
    Item
    No
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    SpinalMRIPerformedInd-2
    Item
    No
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    SpinalMRIPerformedInd-2
    Item
    No
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item
    Will the start of treatment begin within 31 days of initial diagnosis and within 7 days from study enrollment?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    CL.8
    Code List
    Will the start of treatment begin within 31 days of initial diagnosis and within 7 days from study enrollment?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Karnofsky Performance Score
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C28013 (NCI Thesaurus ObjectClass)
    C0206065 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    CL.9
    Code List
    Karnofsky Performance Score
    CL Item
    100 (Normal, no complaints, no evidence of disease.)
    CL Item
    90 (Able to carry on normal activity, minor signs or symptoms of disease.)
    CL Item
    80 (Normal activity with effort, some signs or symptoms of disease.)
    CL Item
    70 (Cares for self. Unable to carry on normal activity or to do active work.)
    CL Item
    60 (Requires occasional assistance, but is able to care for most of own needs.)
    CL Item
    50 (Requires considerable assistance and frequent medical care.)
    CL Item
    40 (Disabled, requires special care and assistance.)
    CL Item
    30 (Severely disabled, hospitalization is indicated although death is not imminent.)
    CL Item
    20 (Hospitalization necessary, very sick, active supportive treatment necessary,)
    CL Item
    10 (Moribund, fatal processes progressing rapidly.)
    CL Item
    0 (Dead.)
    C0919414 (NCI Metathesaurus)
    Item
    Lansky Play Score
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25361 (NCI Thesaurus ObjectClass)
    C0597198 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    CL.10
    Code List
    Lansky Play Score
    CL Item
    100 (Fully active, normal)
    CL Item
    90 (Minor restrictions in physically strenuous activity.)
    CL Item
    80 (Active, but tires more quickly.)
    CL Item
    70 (Both greater restriction of and less time spent in play activity.)
    CL Item
    60 (Up and around, but minimal active play; keeps busy with quieter activities.)
    CL Item
    50 (Gets dressed but lies around much of the day, no active play, able to participate in all quiet play and activities.)
    CL Item
    40 (Mostly in bed; participates in quiet activities.)
    CL Item
    30 (In bed; needs assistance even for quiet play.)
    CL Item
    20 (Often sleeping; play entirely limited to very passive activities.)
    CL Item
    10 (No play; does not get out of bed.)
    CL Item
    0 (Unresponsive.)
    C0919414 (NCI Metathesaurus)
    Item
    Does the patient have a life expectancy of more than or equal to 2 months?
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C37987 (NCI Thesaurus Property)
    C0376558 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    C25359 (NCI Thesaurus Property)
    C0679138 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    Does the patient have a life expectancy of more than or equal to 2 months?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Does the patient have a life expectancy of more than or equal to 2 months?
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C37987 (NCI Thesaurus Property)
    C0376558 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus Property)
    C0013893 (UMLS 2011AA Property)
    C25359 (NCI Thesaurus Property)
    C0679138 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.11
    Code List
    Does the patient have a life expectancy of more than or equal to 2 months?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Has patient received prior treatment other than surgery and corticosteriods?
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C15368 (NCI Thesaurus Property)
    CL.12
    Code List
    Has patient received prior treatment other than surgery and corticosteriods?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Did patient receive growth hormone therapy?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus Property)
    CL.13
    Code List
    Did patient receive growth hormone therapy?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Does the patient have adequate bone marrow function?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25518 (NCI Thesaurus Property)
    C0542341 (UMLS 2011AA Property)
    CL.14
    Code List
    Does the patient have adequate bone marrow function?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Does the patient have adequate renal function?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25518 (NCI Thesaurus Property)
    C0542341 (UMLS 2011AA Property)
    CL.15
    Code List
    Does the patient have adequate renal function?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Does the patient have adequate Central Nervous System function?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25518 (NCI Thesaurus Property)
    C0542341 (UMLS 2011AA Property)
    CL.16
    Code List
    Does the patient have adequate Central Nervous System function?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    is the patient pregnant and/or breastfeeding? (If female,)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25742 (NCI Thesaurus Property)
    C0032961 (UMLS 2011AA Property)
    CL.17
    Code List
    is the patient pregnant and/or breastfeeding? (If female,)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    CL Item
    No, And Not Nursing (no, and not nursing)
    CL Item
    No, But Nursing (no, but nursing)
    Item
    Has the patient and/or their parents or legal guardians signed a written informed consent?
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    CL.18
    Code List
    Has the patient and/or their parents or legal guardians signed a written informed consent?
    CL Item
    Yes (Yes)
    CL Item
    No (No)
    Item
    Have all institutional, FDA, and NCI requirements for human studies been met?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C15206 (NCI Thesaurus ObjectClass)
    C0008972 (UMLS 2011AA ObjectClass)
    C38015 (NCI Thesaurus Property)
    CL.19
    Code List
    Have all institutional, FDA, and NCI requirements for human studies been met?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Ccrr Module For Acns0122 Eligibility Worksheet
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