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ID

6297

Beskrivning

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

Länk

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

Nyckelord

  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 ALLOGENEIC PBSCT TREATMENT FORM - 2071283v3.0

    No Instruction available.

    1. StudyEvent: S0100 ALLOGENEIC PBSCT TREATMENT FORM
      1. No Instruction available.
    Physical
    Beskrivning

    Physical

    Weight (kg)
    Beskrivning

    PatientWeight

    Datatyp

    double

    BSA (2 m)
    Beskrivning

    BodySurfaceArea

    Datatyp

    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
    Beskrivning

    AgentName

    Datatyp

    text

    Start Date
    Beskrivning

    TreatmentStartDate

    Datatyp

    date

    Stop Date
    Beskrivning

    TreatmentEndDate

    Datatyp

    date

    Total dose given (mg)
    Beskrivning

    AgentTotalDose

    Datatyp

    double

    Number of fractions
    Beskrivning

    RTTotalFractionCount

    Datatyp

    double

    Dose Modifications
    Beskrivning

    Dose Modifications

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

    DoseModification(Change)

    Datatyp

    text

    Stem Cell Infusion
    Beskrivning

    Stem Cell Infusion

    Were stem cells infused? (if yes,)
    Beskrivning

    Werestemcellsinfused?

    Datatyp

    text

    date of infusion
    Beskrivning

    Dateoflastperipheralbloodstemcellinfusion

    Datatyp

    text

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

    Totalno.ofCD34+cellsinfused

    Datatyp

    text

    Donor ABO type
    Beskrivning

    DonorABOtype

    Datatyp

    text

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

    PatientABOtype

    Datatyp

    text

    Comments
    Beskrivning

    Comments

    Ccrr Module For S0100 Allogeneic Pbsct Treatment Form
    Beskrivning

    Ccrr Module For S0100 Allogeneic Pbsct Treatment Form

    SWOG Patient ID
    Beskrivning

    SWOGPatientID

    Datatyp

    text

    SWOG Study No.
    Beskrivning

    SWOGStudyNo.

    Datatyp

    text

    Registration Step
    Beskrivning

    RegistrationStep

    Datatyp

    text

    Patient Initials (L, F, M)
    Beskrivning

    PatientInitials

    Datatyp

    text

    Institution/Affiliate
    Beskrivning

    MainMemberInstitution/Affiliate

    Datatyp

    text

    Physician
    Beskrivning

    TreatingPhysician

    Datatyp

    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
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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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