ID

6287

Descripción

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

Link

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

Palabras clave

Versiones (1)
  1. 18/12/14 18/12/14 - Martin Dugas
Subido en

18 de diciembre de 2014

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 POST- PBSCT TREATMENT FORM - 2071416v3.0

Inglés

No Instruction available.

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

Physical

Weight (kg)
Descripción

PatientWeight

Tipo de datos

double

BSA (M2)
Descripción

BodySurfaceArea

Tipo de datos

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Gvhd Prophylaxis
Descripción

Gvhd Prophylaxis

Start Date
Descripción

TreatmentStartDate

Tipo de datos

date

Stop Date
Descripción

TreatmentEndDate

Tipo de datos

date

Growth Factor
Descripción

GrowthFactor

Tipo de datos

text

Other, specify (growth factor)
Descripción

Other,specify(growthfactor)

Tipo de datos

text

Gvhd Treatment
Descripción

Gvhd Treatment

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

DidthepatientdevelopacuteGVHD?

Tipo de datos

text

Start Date
Descripción

TreatmentStartDate

Tipo de datos

date

Date of onset
Descripción

Dateofonset

Tipo de datos

text

Stop Date
Descripción

TreatmentEndDate

Tipo de datos

date

Grade
Descripción

CTCAdverseEventGrade

Tipo de datos

text

Dose Modifications
Descripción

Dose Modifications

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

DoseModification(Change)

Tipo de datos

text

Yes, unplanned, specify change
Descripción

DoseModificationReason

Tipo de datos

text

Chronic Gvhd
Descripción

Chronic Gvhd

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

DidthepatientdevelopchronicGVHD?

Tipo de datos

text

date of onset
Descripción

dateofonset

Tipo de datos

text

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

Extent

Tipo de datos

text

Comments
Descripción

Comments

Tipo de datos

text

Ccrr Module For S0100 Post- Pbsct Treatment Form
Descripción

Ccrr Module For S0100 Post- Pbsct Treatment Form

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F, M)
Descripción

PatientInitials

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician
Descripción

TreatingPhysician

Tipo de datos

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: S0100 POST- PBSCT TREATMENT FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
CL.1
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
CL.2
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
CL.3
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
CL.4
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
CL.5
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
CL.6
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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