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ID

6287

Description

S0100 POST- PBSCT TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB3F489-0AF8-434B-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB3F489-0AF8-434B-E034-0003BA12F5E7

Mots-clés

  1. 18/12/2014 18/12/2014 - Martin Dugas
Téléchargé le

18 décembre 2014

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy

Modèle Commentaires :

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    Leukemia null Treatment - S0100 POST- PBSCT TREATMENT FORM - 2071416v3.0

    No Instruction available.

    1. StudyEvent: S0100 POST- PBSCT TREATMENT FORM
      1. No Instruction available.
    Physical
    Description

    Physical

    Weight (kg)
    Description

    PatientWeight

    Type de données

    double

    BSA (M2)
    Description

    BodySurfaceArea

    Type de données

    double

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25157 (undefined)
    UMLS 2011AA Property
    C0005902 (Body Surface Area)
    SNOMED
    301898006
    Gvhd Prophylaxis
    Description

    Gvhd Prophylaxis

    Start Date
    Description

    TreatmentStartDate

    Type de données

    date

    Stop Date
    Description

    TreatmentEndDate

    Type de données

    date

    Growth Factor
    Description

    GrowthFactor

    Type de données

    text

    Other, specify (growth factor)
    Description

    Other,specify(growthfactor)

    Type de données

    text

    Gvhd Treatment
    Description

    Gvhd Treatment

    Did the patient develop acute GVHD? (If yes)
    Description

    DidthepatientdevelopacuteGVHD?

    Type de données

    text

    Start Date
    Description

    TreatmentStartDate

    Type de données

    date

    Date of onset
    Description

    Dateofonset

    Type de données

    text

    Stop Date
    Description

    TreatmentEndDate

    Type de données

    date

    Grade
    Description

    CTCAdverseEventGrade

    Type de données

    text

    Dose Modifications
    Description

    Dose Modifications

    Were there any dose modifications or additions/omissions to protocol treatment? (check one)
    Description

    DoseModification(Change)

    Type de données

    text

    Yes, unplanned, specify change
    Description

    DoseModificationReason

    Type de données

    text

    Chronic Gvhd
    Description

    Chronic Gvhd

    Did the patient develop chronic GVHD? (If yes,)
    Description

    DidthepatientdevelopchronicGVHD?

    Type de données

    text

    date of onset
    Description

    dateofonset

    Type de données

    text

    Extent (** Explain modifications to dose and/or course and reasons for modification)
    Description

    Extent

    Type de données

    text

    Comments
    Description

    Comments

    Type de données

    text

    Ccrr Module For S0100 Post- Pbsct Treatment Form
    Description

    Ccrr Module For S0100 Post- Pbsct Treatment Form

    SWOG Patient ID
    Description

    SWOGPatientID

    Type de données

    text

    SWOG Study No.
    Description

    SWOGStudyNo.

    Type de données

    text

    Registration Step
    Description

    RegistrationStep

    Type de données

    text

    Patient Initials (L, F, M)
    Description

    PatientInitials

    Type de données

    text

    Institution/Affiliate
    Description

    MainMemberInstitution/Affiliate

    Type de données

    text

    Physician
    Description

    TreatingPhysician

    Type de données

    text

    Alias
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25741 (undefined)
    UMLS 2011AA ObjectClass
    C0031831 (Physicians)
    SNOMED
    158965000
    LOINC
    LA18968-0
    NCI Thesaurus ObjectClass
    C25705 (undefined)
    UMLS 2011AA ObjectClass
    C1522326 (Treating)

    Similar models

    No Instruction available.

    1. StudyEvent: S0100 POST- PBSCT TREATMENT FORM
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Physical
    PatientWeight
    Item
    Weight (kg)
    double
    BodySurfaceArea
    Item
    BSA (M2)
    double
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25157 (NCI Thesaurus Property)
    C0005902 (UMLS 2011AA Property)
    Item Group
    Gvhd Prophylaxis
    TreatmentStartDate
    Item
    Start Date
    date
    TreatmentEndDate
    Item
    Stop Date
    date
    Item
    Growth Factor
    text
    Code List
    Growth Factor
    CL Item
    G-csf (G-CSF)
    CL Item
    Gm-csf (GM-CSF)
    CL Item
    Other, Specify (Other, specify)
    Other,specify(growthfactor)
    Item
    Other, specify (growth factor)
    text
    Item Group
    Gvhd Treatment
    Item
    Did the patient develop acute GVHD? (If yes)
    text
    Code List
    Did the patient develop acute GVHD? (If yes)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    TreatmentStartDate
    Item
    Start Date
    date
    Dateofonset
    Item
    Date of onset
    text
    TreatmentEndDate
    Item
    Stop Date
    date
    Item
    Grade
    text
    Code List
    Grade
    CL Item
    1 (1)
    CL Item
    2 (2)
    CL Item
    3 (3)
    CL Item
    4 (4)
    Item Group
    Dose Modifications
    Item
    Were there any dose modifications or additions/omissions to protocol treatment? (check one)
    text
    Code List
    Were there any dose modifications or additions/omissions to protocol treatment? (check one)
    CL Item
    (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned (i.e., the treatment was changed according to protocol guidelines))
    CL Item
    (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned (i.e., the treatment change was not part of protocol guidelines))
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    DoseModificationReason
    Item
    Yes, unplanned, specify change
    text
    Item Group
    Chronic Gvhd
    Item
    Did the patient develop chronic GVHD? (If yes,)
    text
    Code List
    Did the patient develop chronic GVHD? (If yes,)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    dateofonset
    Item
    date of onset
    text
    Item
    Extent (** Explain modifications to dose and/or course and reasons for modification)
    text
    Code List
    Extent (** Explain modifications to dose and/or course and reasons for modification)
    CL Item
    Limited (Limited)
    CL110648 (NCI Metathesaurus)
    CL Item
    Extensive (Extensive)
    C47863 (NCI Thesaurus)
    C0205231 (UMLS 2011AA)
    Comments
    Item
    Comments
    text
    Item Group
    Ccrr Module For S0100 Post- Pbsct Treatment Form
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    PatientInitials
    Item
    Patient Initials (L, F, M)
    text
    MainMemberInstitution/Affiliate
    Item
    Institution/Affiliate
    text
    TreatingPhysician
    Item
    Physician
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25741 (NCI Thesaurus ObjectClass)
    C0031831 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass)
    C1522326 (UMLS 2011AA ObjectClass)

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