ID
6300
Description
S0100 CNS LEUKEMIA TREATMENT FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB47F23-BC3D-4283-E034-0003BA12F5E7
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Keywords
Versions (1)
- 12/18/14 12/18/14 - Martin Dugas
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December 18, 2014
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License
Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 CNS LEUKEMIA TREATMENT FORM - 2071166v3.0
Instructions: Please complete and submit this form within 14 days after the lumbar puncture. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
Description
Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid
Description
Methotrexate
Description
FirstTreatmentStartDate
Data type
date
Description
Dateoflastdosebeforeblastswereeliminated
Data type
text
Description
AgentTotalDose
Data type
double
Description
AgentAdminRoute
Data type
text
Description
Leucovorin:
Description
Chemotherapy For Cns Leukemia After Elimination Of Blasts From Spinal Fluid
Description
DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?
Data type
text
Description
dateofLPnegativeforCNSinvolvementofALL
Data type
text
Description
DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?
Data type
text
Description
(specifyreason)
Data type
text
Description
Methotrexate
Description
Dateof1stdoseafterblastswereeliminated
Data type
text
Description
AgentTotalDose
Data type
double
Description
TreatmentEndDate
Data type
date
Description
AgentAdminRoute
Data type
text
Description
Dose Modifications
Description
Comments
Description
Ccrr Module For S0100 Cns Leukemia Treatment Form
Description
SWOGPatientID
Data type
text
Description
SWOGStudyNo.
Data type
text
Description
RegistrationStep
Data type
text
Description
PatientInitials
Data type
text
Description
MainMemberInstitution/Affiliate
Data type
text
Description
TreatingPhysician
Data type
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
Instructions: Please complete and submit this form within 14 days after the lumbar puncture. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
C0030705 (UMLS 2011AA ObjectClass)
C25157 (NCI Thesaurus Property)
C0005902 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)