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

Versions (1)
  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

Anglais

No Instruction available.

1 Formulaires  
  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
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
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
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 Formulaires
  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
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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