ID

6300

Beschreibung

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

Stichworte

Versionen (1)
  1. 18.12.14 18.12.14 - Martin Dugas
Hochgeladen am

18. Dezember 2014

DOI

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Creative Commons BY-NC 3.0 Legacy
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Leukemia null Treatment - S0100 CNS LEUKEMIA TREATMENT FORM - 2071166v3.0

Englisch

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 Formulare  
Physical
Beschreibung

Physical

Weight (kg)
Beschreibung

PatientWeight

Datentyp

double

BSA (2 m)
Beschreibung

BodySurfaceArea

Datentyp

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
Beschreibung

Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid

Did the patient receive chemotherapy for CNS leukemia?
Beschreibung

DidthepatientreceivechemotherapyforCNSleukemia?

Datentyp

text

Methotrexate
Beschreibung

Methotrexate

Start Date:
Beschreibung

FirstTreatmentStartDate

Datentyp

date

Date of last dose before blasts were eliminated
Beschreibung

Dateoflastdosebeforeblastswereeliminated

Datentyp

text

Total dose given (mg)
Beschreibung

AgentTotalDose

Datentyp

double

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

AgentAdminRoute

Datentyp

text

Leucovorin:
Beschreibung

Leucovorin:

Start Date:
Beschreibung

FirstTreatmentStartDate

Datentyp

date

Date of last dose before blasts were eliminated:
Beschreibung

Dateoflastdosebeforeblastswereeliminated:

Datentyp

text

Total dose given (mg)
Beschreibung

AgentTotalDose

Datentyp

double

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

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)
Beschreibung

DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?

Datentyp

text

date of LP negative for CNS involvement of ALL
Beschreibung

dateofLPnegativeforCNSinvolvementofALL

Datentyp

text

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

DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?

Datentyp

text

(specify reason)
Beschreibung

(specifyreason)

Datentyp

text

Methotrexate
Beschreibung

Methotrexate

Date of 1st dose after blasts were eliminated
Beschreibung

Dateof1stdoseafterblastswereeliminated

Datentyp

text

Total dose given (mg)
Beschreibung

AgentTotalDose

Datentyp

double

Stop Date
Beschreibung

TreatmentEndDate

Datentyp

date

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

AgentAdminRoute

Datentyp

text

Dose Modifications
Beschreibung

Dose Modifications

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

DoseModification(Change)

Datentyp

text

Comments
Beschreibung

Comments

Ccrr Module For S0100 Cns Leukemia Treatment Form
Beschreibung

Ccrr Module For S0100 Cns Leukemia Treatment Form

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F, M)
Beschreibung

PatientInitials

Datentyp

text

Institution/Affiliate
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Physician
Beschreibung

TreatingPhysician

Datentyp

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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Ähnliche Modelle

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 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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