ID

6300

Descrizione

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

collegamento

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

Keywords

  1. 18/12/14 18/12/14 - Martin Dugas
Caricato su

18 dicembre 2014

DOI

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Licenza

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.

Physical
Descrizione

Physical

Weight (kg)
Descrizione

PatientWeight

Tipo di dati

double

BSA (2 m)
Descrizione

BodySurfaceArea

Tipo di dati

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
Descrizione

Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid

Did the patient receive chemotherapy for CNS leukemia?
Descrizione

DidthepatientreceivechemotherapyforCNSleukemia?

Tipo di dati

text

Methotrexate
Descrizione

Methotrexate

Start Date:
Descrizione

FirstTreatmentStartDate

Tipo di dati

date

Date of last dose before blasts were eliminated
Descrizione

Dateoflastdosebeforeblastswereeliminated

Tipo di dati

text

Total dose given (mg)
Descrizione

AgentTotalDose

Tipo di dati

double

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

AgentAdminRoute

Tipo di dati

text

Leucovorin:
Descrizione

Leucovorin:

Start Date:
Descrizione

FirstTreatmentStartDate

Tipo di dati

date

Date of last dose before blasts were eliminated:
Descrizione

Dateoflastdosebeforeblastswereeliminated:

Tipo di dati

text

Total dose given (mg)
Descrizione

AgentTotalDose

Tipo di dati

double

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

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)
Descrizione

DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?

Tipo di dati

text

date of LP negative for CNS involvement of ALL
Descrizione

dateofLPnegativeforCNSinvolvementofALL

Tipo di dati

text

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

DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?

Tipo di dati

text

(specify reason)
Descrizione

(specifyreason)

Tipo di dati

text

Methotrexate
Descrizione

Methotrexate

Date of 1st dose after blasts were eliminated
Descrizione

Dateof1stdoseafterblastswereeliminated

Tipo di dati

text

Total dose given (mg)
Descrizione

AgentTotalDose

Tipo di dati

double

Stop Date
Descrizione

TreatmentEndDate

Tipo di dati

date

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

AgentAdminRoute

Tipo di dati

text

Dose Modifications
Descrizione

Dose Modifications

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

DoseModification(Change)

Tipo di dati

text

Comments
Descrizione

Comments

Ccrr Module For S0100 Cns Leukemia Treatment Form
Descrizione

Ccrr Module For S0100 Cns Leukemia 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

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.

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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
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
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
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
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
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
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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