ID

6297

Description

S0100 ALLOGENEIC PBSCT TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB397EC-8B44-42D5-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB397EC-8B44-42D5-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 ALLOGENEIC PBSCT TREATMENT FORM - 2071283v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 ALLOGENEIC PBSCT 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

AgentName

Data type

text

Start Date
Description

TreatmentStartDate

Data type

date

Stop Date
Description

TreatmentEndDate

Data type

date

Total dose given (mg)
Description

AgentTotalDose

Data type

double

Number of fractions
Description

RTTotalFractionCount

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

Stem Cell Infusion
Description

Stem Cell Infusion

Were stem cells infused? (if yes,)
Description

Werestemcellsinfused?

Data type

text

date of infusion
Description

Dateoflastperipheralbloodstemcellinfusion

Data type

text

CD34 cells infused (6 X 10 cells/kg)
Description

Totalno.ofCD34+cellsinfused

Data type

text

Donor ABO type
Description

DonorABOtype

Data type

text

Patient ABO type (** Explain modifications to dose and/or course and reasons for modification)
Description

PatientABOtype

Data type

text

Comments
Description

Comments

Ccrr Module For S0100 Allogeneic Pbsct Treatment Form
Description

Ccrr Module For S0100 Allogeneic Pbsct 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
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No Instruction available.

1 forms
  1. StudyEvent: S0100 ALLOGENEIC PBSCT 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
TREATMENT
text
CL.1
Code List
TREATMENT
CL Item
VP-16 (VP-16)
CL Item
TBI (TBI)
CL Item
Testicular Boost (Testicular Boost)
CL Item
Allopurinol (Allopurinol)
TreatmentStartDate
Item
Start Date
date
TreatmentEndDate
Item
Stop Date
date
AgentTotalDose
Item
Total dose given (mg)
double
RTTotalFractionCount
Item
Number of fractions
double
Item Group
Dose Modifications
Item
Were there any dose modifications or additions/omissions to protocol treatment? (check one)
text
CL.2
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)
Item Group
Stem Cell Infusion
Item
Were stem cells infused? (if yes,)
text
CL.3
Code List
Were stem cells infused? (if yes,)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Dateoflastperipheralbloodstemcellinfusion
Item
date of infusion
text
Totalno.ofCD34+cellsinfused
Item
CD34 cells infused (6 X 10 cells/kg)
text
Item
Donor ABO type
text
CL.4
Code List
Donor ABO type
CL Item
A (A)
C14653 (NCI Thesaurus)
CL Item
B (B)
CL Item
Ab (AB)
CL Item
O (O)
Item
Patient ABO type (** Explain modifications to dose and/or course and reasons for modification)
text
CL.5
Code List
Patient ABO type (** Explain modifications to dose and/or course and reasons for modification)
CL Item
A (A)
C14653 (NCI Thesaurus)
CL Item
B (B)
CL Item
Ab (AB)
CL Item
O (O)
Item Group
Comments
Item Group
Ccrr Module For S0100 Allogeneic 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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