ID

6291

Beschreibung

S0100 CONSOLIDATION TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB45C27-2314-425F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB45C27-2314-425F-E034-0003BA12F5E7

Stichworte

Versionen (1)
  1. 18.12.14 18.12.14 - Martin Dugas
Hochgeladen am

18. Dezember 2014

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 CONSOLIDATION TREATMENT FORM - 2070989v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: S0100 CONSOLIDATION TREATMENT FORM
    1. No Instruction available.
Physical
Beschreibung

Physical

Weight (kg)
Beschreibung

PatientWeight

Datentyp

double

BSA (M2)
Beschreibung

BodySurfaceArea

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Chemotherapy
Beschreibung

Chemotherapy

Consolidation Regimen (check only one:)
Beschreibung

ConsolidationRegimen

Datentyp

text

Other, specify (treatment)
Beschreibung

AgentName

Datentyp

text

Other, specify (treatment)
Beschreibung

AgentName

Datentyp

text

Start Date
Beschreibung

TreatmentStartDate

Datentyp

date

Stop Date
Beschreibung

TreatmentEndDate

Datentyp

date

Total dose given
Beschreibung

AgentTotalDose

Datentyp

double

Chemotherapy Dose Modifications
Beschreibung

Chemotherapy Dose Modifications

Were there any dose/fractionation modifications or additions/omissions from protocol treatment? (check one)
Beschreibung

DoseModification(Change)

Datentyp

text

Cranial Irradiation For Cns Leukemia
Beschreibung

Cranial Irradiation For Cns Leukemia

Did the patient require cranial irradiation according to the protocol? (check one)
Beschreibung

Didthepatientrequirecranialirradiationaccordingtotheprotocol?

Datentyp

text

Did this patient receive protocol cranial irradiation?
Beschreibung

Didthispatientreceiveprotocolcranialirradiation?

Datentyp

text

Start Date (RT)
Beschreibung

RTBeginDate

Datentyp

date

Stop Date (RT)
Beschreibung

RTEndDate

Datentyp

date

Total dose given (RT)
Beschreibung

RTTotalDose

Datentyp

double

Cranial Irradiation Dose Modifications
Beschreibung

Cranial Irradiation Dose Modifications

Were there any dose/fractionation modifications or additions/omissions from protocol treatment? (check one)
Beschreibung

DoseModification(Change)

Datentyp

text

Comments
Beschreibung

Comments

Datentyp

text

Ccrr Module For S0100 Consolidation Treatment Form
Beschreibung

Ccrr Module For S0100 Consolidation Treatment Form

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F, M)
Beschreibung

PatientInitials

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Physician
Beschreibung

TreatingPhysician

Datentyp

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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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: S0100 CONSOLIDATION TREATMENT FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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
Chemotherapy
Item
Consolidation Regimen (check only one:)
text
CL.1
Code List
Consolidation Regimen (check only one:)
CL Item
Cyclophosphamide/ara-c/6-mp/mtx (Cyclophosphamide/Ara-C/6-MP/MTX)
CL Item
Mtx/prednisone/vincristine (MTX/Prednisone/Vincristine)
AgentName
Item
Other, specify (treatment)
text
AgentName
Item
Other, specify (treatment)
text
TreatmentStartDate
Item
Start Date
date
TreatmentEndDate
Item
Stop Date
date
AgentTotalDose
Item
Total dose given
double
Item Group
Chemotherapy Dose Modifications
Item
Were there any dose/fractionation modifications or additions/omissions from protocol treatment? (check one)
text
CL.6
Code List
Were there any dose/fractionation modifications or additions/omissions from 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)
Item Group
Cranial Irradiation For Cns Leukemia
Item
Did the patient require cranial irradiation according to the protocol? (check one)
text
CL.4
Code List
Did the patient require cranial irradiation according to the protocol? (check one)
CL Item
Yes, For Treatment Of Cns Involvement (Yes, for treatment of CNS involvement)
CL Item
Yes, For Cns Prophylaxis In A Patient Not Expected To Receive Allogeneic Pbsct (Yes, for CNS prophylaxis in a patient not expected to receive allogeneic PBSCT)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Did this patient receive protocol cranial irradiation?
text
CL.5
Code List
Did this patient receive protocol cranial irradiation?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
RTBeginDate
Item
Start Date (RT)
date
RTEndDate
Item
Stop Date (RT)
date
RTTotalDose
Item
Total dose given (RT)
double
Item Group
Cranial Irradiation Dose Modifications
Item
Were there any dose/fractionation modifications or additions/omissions from protocol treatment? (check one)
text
CL.6
Code List
Were there any dose/fractionation modifications or additions/omissions from 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)
Comments
Item
Comments
text
Item Group
Ccrr Module For S0100 Consolidation 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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