ID

6291

Beschrijving

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

Trefwoorden

Versies (1)
  1. 18-12-14 18-12-14 - Martin Dugas
Geüploaded op

18 december 2014

DOI

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Licentie

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

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0100 CONSOLIDATION TREATMENT FORM
    1. No Instruction available.
Physical
Beschrijving

Physical

Weight (kg)
Beschrijving

PatientWeight

Datatype

double

BSA (M2)
Beschrijving

BodySurfaceArea

Datatype

double

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

Chemotherapy

Consolidation Regimen (check only one:)
Beschrijving

ConsolidationRegimen

Datatype

text

Other, specify (treatment)
Beschrijving

AgentName

Datatype

text

Other, specify (treatment)
Beschrijving

AgentName

Datatype

text

Start Date
Beschrijving

TreatmentStartDate

Datatype

date

Stop Date
Beschrijving

TreatmentEndDate

Datatype

date

Total dose given
Beschrijving

AgentTotalDose

Datatype

double

Chemotherapy Dose Modifications
Beschrijving

Chemotherapy Dose Modifications

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

DoseModification(Change)

Datatype

text

Cranial Irradiation For Cns Leukemia
Beschrijving

Cranial Irradiation For Cns Leukemia

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

Didthepatientrequirecranialirradiationaccordingtotheprotocol?

Datatype

text

Did this patient receive protocol cranial irradiation?
Beschrijving

Didthispatientreceiveprotocolcranialirradiation?

Datatype

text

Start Date (RT)
Beschrijving

RTBeginDate

Datatype

date

Stop Date (RT)
Beschrijving

RTEndDate

Datatype

date

Total dose given (RT)
Beschrijving

RTTotalDose

Datatype

double

Cranial Irradiation Dose Modifications
Beschrijving

Cranial Irradiation Dose Modifications

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

DoseModification(Change)

Datatype

text

Comments
Beschrijving

Comments

Datatype

text

Ccrr Module For S0100 Consolidation Treatment Form
Beschrijving

Ccrr Module For S0100 Consolidation Treatment Form

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F, M)
Beschrijving

PatientInitials

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
Beschrijving

TreatingPhysician

Datatype

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 Formulieren
  1. StudyEvent: S0100 CONSOLIDATION TREATMENT FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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