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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

  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

    No Instruction available.

    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 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus Property
    C25157 (undefined)
    UMLS 2011AA Property
    C0005902 (Body Surface Area)
    SNOMED
    301898006
    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 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    NCI Thesaurus ObjectClass
    C25741 (undefined)
    UMLS 2011AA ObjectClass
    C0031831 (Physicians)
    SNOMED
    158965000
    LOINC
    LA18968-0
    NCI Thesaurus ObjectClass
    C25705 (undefined)
    UMLS 2011AA ObjectClass
    C1522326 (Treating)

    Similar models

    No Instruction available.

    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
    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
    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
    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
    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
    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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