ID

6300

Beskrivning

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

Länk

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

Nyckelord

Versioner (1)
  1. 2014-12-18 2014-12-18 - Martin Dugas
Uppladdad den

18 december 2014

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Leukemia null Treatment - S0100 CNS LEUKEMIA TREATMENT FORM - 2071166v3.0

Engelsk

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 Formulär  
Physical
Beskrivning

Physical

Weight (kg)
Beskrivning

PatientWeight

Datatyp

double

BSA (2 m)
Beskrivning

BodySurfaceArea

Datatyp

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
Beskrivning

Chemotherapy For Cns Leukemia Before Elimination Of Blasts From Spinal Fluid

Did the patient receive chemotherapy for CNS leukemia?
Beskrivning

DidthepatientreceivechemotherapyforCNSleukemia?

Datatyp

text

Methotrexate
Beskrivning

Methotrexate

Start Date:
Beskrivning

FirstTreatmentStartDate

Datatyp

date

Date of last dose before blasts were eliminated
Beskrivning

Dateoflastdosebeforeblastswereeliminated

Datatyp

text

Total dose given (mg)
Beskrivning

AgentTotalDose

Datatyp

double

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

AgentAdminRoute

Datatyp

text

Leucovorin:
Beskrivning

Leucovorin:

Start Date:
Beskrivning

FirstTreatmentStartDate

Datatyp

date

Date of last dose before blasts were eliminated:
Beskrivning

Dateoflastdosebeforeblastswereeliminated:

Datatyp

text

Total dose given (mg)
Beskrivning

AgentTotalDose

Datatyp

double

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

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)
Beskrivning

DidthepatienthaveanLPthatwasnegativeforCNSinvolvementofALL?

Datatyp

text

date of LP negative for CNS involvement of ALL
Beskrivning

dateofLPnegativeforCNSinvolvementofALL

Datatyp

text

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

DidthepatientreceiveprotocolchemotherapyforCNSleukemiaaftereliminationofblastsfromspinalfluid?

Datatyp

text

(specify reason)
Beskrivning

(specifyreason)

Datatyp

text

Methotrexate
Beskrivning

Methotrexate

Date of 1st dose after blasts were eliminated
Beskrivning

Dateof1stdoseafterblastswereeliminated

Datatyp

text

Total dose given (mg)
Beskrivning

AgentTotalDose

Datatyp

double

Stop Date
Beskrivning

TreatmentEndDate

Datatyp

date

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

AgentAdminRoute

Datatyp

text

Dose Modifications
Beskrivning

Dose Modifications

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

DoseModification(Change)

Datatyp

text

Comments
Beskrivning

Comments

Ccrr Module For S0100 Cns Leukemia Treatment Form
Beskrivning

Ccrr Module For S0100 Cns Leukemia Treatment Form

SWOG Patient ID
Beskrivning

SWOGPatientID

Datatyp

text

SWOG Study No.
Beskrivning

SWOGStudyNo.

Datatyp

text

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient Initials (L, F, M)
Beskrivning

PatientInitials

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Physician
Beskrivning

TreatingPhysician

Datatyp

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
Tillbaka till toppen

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 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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)
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial