ID

6297

Descrizione

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

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB397EC-8B44-42D5-E034-0003BA12F5E7

Keywords

  1. 18/12/14 18/12/14 - Martin Dugas
Caricato su

18 dicembre 2014

DOI

Per favore, per richiedere un accesso.

Licenza

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
Descrizione

Physical

Weight (kg)
Descrizione

PatientWeight

Tipo di dati

double

BSA (2 m)
Descrizione

BodySurfaceArea

Tipo di dati

double

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

AgentName

Tipo di dati

text

Start Date
Descrizione

TreatmentStartDate

Tipo di dati

date

Stop Date
Descrizione

TreatmentEndDate

Tipo di dati

date

Total dose given (mg)
Descrizione

AgentTotalDose

Tipo di dati

double

Number of fractions
Descrizione

RTTotalFractionCount

Tipo di dati

double

Dose Modifications
Descrizione

Dose Modifications

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

DoseModification(Change)

Tipo di dati

text

Stem Cell Infusion
Descrizione

Stem Cell Infusion

Were stem cells infused? (if yes,)
Descrizione

Werestemcellsinfused?

Tipo di dati

text

date of infusion
Descrizione

Dateoflastperipheralbloodstemcellinfusion

Tipo di dati

text

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

Totalno.ofCD34+cellsinfused

Tipo di dati

text

Donor ABO type
Descrizione

DonorABOtype

Tipo di dati

text

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

PatientABOtype

Tipo di dati

text

Comments
Descrizione

Comments

Ccrr Module For S0100 Allogeneic Pbsct Treatment Form
Descrizione

Ccrr Module For S0100 Allogeneic Pbsct Treatment Form

SWOG Patient ID
Descrizione

SWOGPatientID

Tipo di dati

text

SWOG Study No.
Descrizione

SWOGStudyNo.

Tipo di dati

text

Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Patient Initials (L, F, M)
Descrizione

PatientInitials

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Physician
Descrizione

TreatingPhysician

Tipo di dati

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
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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