Information:
Fel:
ID
6296
Beskrivning
S0100 INDUCTION TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB42946-1315-41FD-E034-0003BA12F5E7
Länk
Nyckelord
Versioner (1)
- 2014-12-18 2014-12-18 - Martin Dugas
Uppladdad den
18 december 2014
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 INDUCTION TREATMENT FORM - 2070861v3.0
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- StudyEvent: S0100 INDUCTION TREATMENT FORM
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- StudyEvent: S0100 INDUCTION TREATMENT FORM
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
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)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
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
Were there any dose modifications or additions/omissions to protocol treatment? (check one)
text
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)
C1298908 (UMLS 2011AA)
DoseModificationReason
Item
Yes, unplanned, specify change
text
Comments
Item
Comments
text
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)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
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)