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

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB47F23-BC3D-4283-E034-0003BA12F5E7

Keywords

Versions (1)
  1. 12/18/14 12/18/14 - Martin Dugas
Uploaded on

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

English

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.

1 forms  
Physical
Description

Physical

Weight (kg)
Description

PatientWeight

Data type

double

BSA (2 m)
Description

BodySurfaceArea

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25157
UMLS 2011AA Property
C0005902
Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid
Description

Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid

Did the patient receive chemotherapy for CNS leukemia?
Description

DidthepatientreceivechemotherapyforCNSleukemia?

Data type

text

Methotrexate
Description

Methotrexate

Start Date:
Description

FirstTreatmentStartDate

Data type

date

Date of last dose before blasts were eliminated
Description

Dateoflastdosebeforeblastswereeliminated

Data type

text

Total dose given (mg)
Description

AgentTotalDose

Data type

double

Route(s) of administration (check all that apply:)
Description

AgentAdminRoute

Data type

text

Leucovorin:
Description

Leucovorin:

Start Date:
Description

FirstTreatmentStartDate

Data type

date

Date of last dose before blasts were eliminated:
Description

Dateoflastdosebeforeblastswereeliminated:

Data type

text

Total dose given (mg)
Description

AgentTotalDose

Data type

double

Chemotherapy For Cns Leukemia After Elimination Of Blasts From Spinal Fluid
Description

Chemotherapy For Cns Leukemia After Elimination Of Blasts From Spinal Fluid

Did the patient have an LP that was negative for CNS involvement of ALL? (If yes)
Description

DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?

Data type

text

date of LP negative for CNS involvement of ALL
Description

dateofLPnegativeforCNSinvolvementofALL

Data type

text

Did the patient receive protocol chemotherapy for CNS leukemia after elimination of blasts from spinal fluid?
Description

DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?

Data type

text

(specify reason)
Description

(specifyreason)

Data type

text

Methotrexate
Description

Methotrexate

Date of 1st dose after blasts were eliminated
Description

Dateof1stdoseafterblastswereeliminated

Data type

text

Total dose given (mg)
Description

AgentTotalDose

Data type

double

Stop Date
Description

TreatmentEndDate

Data type

date

Route(s) of administration (check all that apply:)
Description

AgentAdminRoute

Data type

text

Dose Modifications
Description

Dose Modifications

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

DoseModification(Change)

Data type

text

Comments
Description

Comments

Ccrr Module For S0100 Cns Leukemia Treatment Form
Description

Ccrr Module For S0100 Cns Leukemia Treatment Form

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
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
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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.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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 Group
Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid
Item
Did the patient receive chemotherapy for CNS leukemia?
text
CL.1
Code List
Did the patient receive chemotherapy for CNS leukemia?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Methotrexate
FirstTreatmentStartDate
Item
Start Date:
date
Dateoflastdosebeforeblastswereeliminated
Item
Date of last dose before blasts were eliminated
text
AgentTotalDose
Item
Total dose given (mg)
double
Item
Route(s) of administration (check all that apply:)
text
CL.5
Code List
Route(s) of administration (check all that apply:)
CL Item
Intrathecal (Intrathecal)
CL Item
Intraventricular (Intraventricular)
Item Group
Leucovorin:
FirstTreatmentStartDate
Item
Start Date:
date
Dateoflastdosebeforeblastswereeliminated:
Item
Date of last dose before blasts were eliminated:
text
AgentTotalDose
Item
Total dose given (mg)
double
Item Group
Chemotherapy For Cns Leukemia After Elimination Of Blasts From Spinal Fluid
Item
Did the patient have an LP that was negative for CNS involvement of ALL? (If yes)
text
CL.3
Code List
Did the patient have an LP that was negative for CNS involvement of ALL? (If yes)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
dateofLPnegativeforCNSinvolvementofALL
Item
date of LP negative for CNS involvement of ALL
text
Item
Did the patient receive protocol chemotherapy for CNS leukemia after elimination of blasts from spinal fluid?
text
CL.4
Code List
Did the patient receive protocol chemotherapy for CNS leukemia after elimination of blasts from spinal fluid?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
(specifyreason)
Item
(specify reason)
text
Item Group
Methotrexate
Dateof1stdoseafterblastswereeliminated
Item
Date of 1st dose after blasts were eliminated
text
AgentTotalDose
Item
Total dose given (mg)
double
TreatmentEndDate
Item
Stop Date
date
Item
Route(s) of administration (check all that apply:)
text
CL.5
Code List
Route(s) of administration (check all that apply:)
CL Item
Intrathecal (Intrathecal)
CL Item
Intraventricular (Intraventricular)
Item Group
Dose Modifications
Item
Were there any dose/fractionation modifications or additions/omissions to protocol treatment? (check one)
text
CL.6
Code List
Were there any dose/fractionation 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
Comments
Item Group
Ccrr Module For S0100 Cns Leukemia 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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