ID

6297

Descripción

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

Palabras clave

  1. 18/12/14 18/12/14 - Martin Dugas
Subido en

18 de diciembre de 2014

DOI

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Licencia

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
Descripción

Physical

Weight (kg)
Descripción

PatientWeight

Tipo de datos

double

BSA (2 m)
Descripción

BodySurfaceArea

Tipo de datos

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
TREATMENT
Descripción

AgentName

Tipo de datos

text

Start Date
Descripción

TreatmentStartDate

Tipo de datos

date

Stop Date
Descripción

TreatmentEndDate

Tipo de datos

date

Total dose given (mg)
Descripción

AgentTotalDose

Tipo de datos

double

Number of fractions
Descripción

RTTotalFractionCount

Tipo de datos

double

Dose Modifications
Descripción

Dose Modifications

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

DoseModification(Change)

Tipo de datos

text

Stem Cell Infusion
Descripción

Stem Cell Infusion

Were stem cells infused? (if yes,)
Descripción

Werestemcellsinfused?

Tipo de datos

text

date of infusion
Descripción

Dateoflastperipheralbloodstemcellinfusion

Tipo de datos

text

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

Totalno.ofCD34+cellsinfused

Tipo de datos

text

Donor ABO type
Descripción

DonorABOtype

Tipo de datos

text

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

PatientABOtype

Tipo de datos

text

Comments
Descripción

Comments

Ccrr Module For S0100 Allogeneic Pbsct Treatment Form
Descripción

Ccrr Module For S0100 Allogeneic Pbsct Treatment Form

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F, M)
Descripción

PatientInitials

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician
Descripción

TreatingPhysician

Tipo de datos

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

Similar models

No Instruction available.

  1. StudyEvent: S0100 ALLOGENEIC PBSCT TREATMENT FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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