ID

6296

Description

S0100 INDUCTION TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB42946-1315-41FD-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB42946-1315-41FD-E034-0003BA12F5E7

Keywords

Versions (1)
  1. 12/18/14 12/18/14 - Martin Dugas
Uploaded on

December 18, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 INDUCTION TREATMENT FORM - 2070861v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 INDUCTION TREATMENT FORM
    1. No Instruction available.
Physical
Description

Physical

Weight (kg)
Description

PatientWeight

Data type

double

BSA (2 m)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Treatment
Description

Treatment

Induction Regimen (check only one)
Description

InductionRegimen

Data type

text

Other, specify
Description

AgentName

Data type

text

Other, specify
Description

AgentName

Data type

text

Other, specify
Description

AgentName

Data type

text

Start Date
Description

TreatmentStartDate

Data type

date

Stop Date
Description

TreatmentEndDate

Data type

date

Total dose given
Description

AgentTotalDose

Data type

double

Dose Modifications
Description

Dose Modifications

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

DoseModification(Change)

Data type

text

Yes, unplanned, specify change
Description

DoseModificationReason

Data type

text

Comments
Description

Comments

Data type

text

Ccrr Module For S0100 Induction Treatment Form
Description

Ccrr Module For S0100 Induction Treatment Form

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

TreatingPhysician

Data type

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
Cycle
Description

TreatmentPhase

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: S0100 INDUCTION TREATMENT FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Physical
PatientWeight
Item
Weight (kg)
double
BodySurfaceArea
Item
BSA (2 m)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item Group
Treatment
Item
Induction Regimen (check only one)
text
CL.1
Code List
Induction Regimen (check only one)
CL Item
Daunorubicin/vincristine/prednisone/l-asparaginase (Daunorubicin/Vincristine/Prednisone/L-asparaginase)
CL Item
High Dose Ara-c/mitoxantrone (High dose Ara-C/Mitoxantrone)
AgentName
Item
Other, specify
text
AgentName
Item
Other, specify
text
AgentName
Item
Other, specify
text
TreatmentStartDate
Item
Start Date
date
TreatmentEndDate
Item
Stop Date
date
AgentTotalDose
Item
Total dose given
double
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
Comments
Item
Comments
text
Item Group
Ccrr Module For S0100 Induction 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)
Item
Cycle
text
CL.5
Code List
Cycle
CL Item
Current Phase Of Leukemia Treatment For Patient Is Induction (First Induction)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Crossover (Cross-over Induction)
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