ID

6300

Descrição

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

Palavras-chave

Versões (1)
  1. 18/12/2014 18/12/2014 - Martin Dugas
Transferido a

18 de dezembro de 2014

DOI

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Licença

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

Inglês

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 Formulários  
Physical
Descrição

Physical

Weight (kg)
Descrição

PatientWeight

Tipo de dados

double

BSA (2 m)
Descrição

BodySurfaceArea

Tipo de dados

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
Descrição

Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid

Did the patient receive chemotherapy for CNS leukemia?
Descrição

DidthepatientreceivechemotherapyforCNSleukemia?

Tipo de dados

text

Methotrexate
Descrição

Methotrexate

Start Date:
Descrição

FirstTreatmentStartDate

Tipo de dados

date

Date of last dose before blasts were eliminated
Descrição

Dateoflastdosebeforeblastswereeliminated

Tipo de dados

text

Total dose given (mg)
Descrição

AgentTotalDose

Tipo de dados

double

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

AgentAdminRoute

Tipo de dados

text

Leucovorin:
Descrição

Leucovorin:

Start Date:
Descrição

FirstTreatmentStartDate

Tipo de dados

date

Date of last dose before blasts were eliminated:
Descrição

Dateoflastdosebeforeblastswereeliminated:

Tipo de dados

text

Total dose given (mg)
Descrição

AgentTotalDose

Tipo de dados

double

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

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)
Descrição

DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?

Tipo de dados

text

date of LP negative for CNS involvement of ALL
Descrição

dateofLPnegativeforCNSinvolvementofALL

Tipo de dados

text

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

DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?

Tipo de dados

text

(specify reason)
Descrição

(specifyreason)

Tipo de dados

text

Methotrexate
Descrição

Methotrexate

Date of 1st dose after blasts were eliminated
Descrição

Dateof1stdoseafterblastswereeliminated

Tipo de dados

text

Total dose given (mg)
Descrição

AgentTotalDose

Tipo de dados

double

Stop Date
Descrição

TreatmentEndDate

Tipo de dados

date

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

AgentAdminRoute

Tipo de dados

text

Dose Modifications
Descrição

Dose Modifications

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

DoseModification(Change)

Tipo de dados

text

Comments
Descrição

Comments

Ccrr Module For S0100 Cns Leukemia Treatment Form
Descrição

Ccrr Module For S0100 Cns Leukemia Treatment Form

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient Initials (L, F, M)
Descrição

PatientInitials

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Physician
Descrição

TreatingPhysician

Tipo de dados

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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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