ID

6298

Descrizione

S0100 MAINTENANCE TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50F10-EF45-43A0-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB50F10-EF45-43A0-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 MAINTENANCE TREATMENT FORM - 2071555v3.0

No Instruction available.

  1. StudyEvent: S0100 MAINTENANCE TREATMENT FORM
    1. No Instruction available.
Physical
Descrizione

Physical

Weight (kg)
Descrizione

PatientWeight

Tipo di dati

double

BSA (M2)
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

Treatment

Other growth factor, specify
Descrizione

AgentName

Tipo di dati

text

Other growth factor, specify
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
Descrizione

AgentTotalDose

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

Yes, Unplanned, specify change (** Explain modifications to dose and/or course and reasons for modification)
Descrizione

DoseModificationReason

Tipo di dati

text

Comments
Descrizione

Comments

Ccrr Module For S0100 Maintenance Treatment Form
Descrizione

Ccrr Module For S0100 Maintenance 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
Cycle (check only one)
Descrizione

CourseIdentification

Tipo di dati

text

Similar models

No Instruction available.

  1. StudyEvent: S0100 MAINTENANCE 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 (M2)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
Item Group
Treatment
AgentName
Item
Other growth factor, specify
text
AgentName
Item
Other growth factor, specify
text
TreatmentStartDate
Item
Start Date
date
TreatmentEndDate
Item
Stop Date
date
AgentTotalDose
Item
Total dose given
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)
DoseModificationReason
Item
Yes, Unplanned, specify change (** Explain modifications to dose and/or course and reasons for modification)
text
Item Group
Comments
Item Group
Ccrr Module For S0100 Maintenance 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)
Item
Cycle (check only one)
text
Code List
Cycle (check only one)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)

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