ID

10481

Description

ECOG Leukemia Cytogenetics Report Form 2053765v3.0 Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E3BC-7882-2F82-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E3BC-7882-2F82-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 6/2/15 6/2/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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ECOG Leukemia Cytogenetics Report Form 2053765v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: ECOG Leukemia Cytogenetics Report Form
    1. No Instruction available.
ECOG clinical trial administrative data
Description

ECOG clinical trial administrative data

Cytogeneticist
Description

CytogeneticsIdentifier

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C16487
UMLS 2011AA ObjectClass
C0010802
Phone No.
Description

PhoneNumber

Data type

double

Patient's Name
Description

Patient'sName

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient Seq. No.
Description

ECOGPatientID

Data type

text

ECOG Patient Seq. No.
Description

ECOGPatientID

Data type

text

Participating Group Prot. No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID no.
Description

ParticipatingGroupPatientID

Data type

text

Group
Description

ParticipatingGroupName

Data type

text

Institution
Description

InstitutionName

Data type

text

Step No.
Description

StepNo.

Data type

text

Affiliate
Description

AffiliateName

Data type

text

Cytogenetics samples
Description

Cytogenetics samples

Date sample obtained
Description

Datesampleobtained

Data type

text

Is Extra material stored?
Description

SpecimenRemainingStorageInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25649
UMLS 2011AA Property
C1527428
NCI Thesaurus Property
C60824
UMLS 2011AA Property
C1698986
If yes, specify type (extra material)
Description

SpecimenRemainingStorageName

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
NCI Thesaurus Property
C25649
UMLS 2011AA Property
C1527428
NCI Thesaurus Property
C60824
UMLS 2011AA Property
C1698986
Number Of Metaphases
Description

Number Of Metaphases

Bone Marrow, unsimulated short-term culture (metaphases)
Description

BoneMarrowMetaphasePresentNumber

Data type

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
Bone Marrow, direct preparation (metaphases)
Description

BoneMarrowDirectMetaphasePresentNumber

Data type

double

Alias
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
NCI Metathesaurus ObjectClass
C0439851
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Bone Marrow, Stimulated Culture (metaphases)
Description

BoneMarrowCultureMetaphasePresentNumber

Data type

double

Alias
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Bone Marrow, Stimulated Culture, Specify mitogen (metaphases)
Description

BoneMarrowCultureMitogenDescriptionText

Data type

text

Alias
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
NCI Thesaurus ObjectClass
C660
UMLS 2011AA ObjectClass
C0026249
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Bone Marrow, Other Specify (metaphases)
Description

BoneMarrowCultureMethodText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
Bone Marrow, Other Specify (metaphases)
Description

BoneMarrowCultureMethodText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
Peripheral Blood, unsimulated short-term culture (metaphases)
Description

PeripheralBloodMetaphasePresentNumber

Data type

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Metathesaurus ObjectClass
C0229664
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
Peripheral Bood, direct preparation (metaphases)
Description

PeripheralBood,directpreparation(metaphases)

Data type

text

Peripheral Bood, Stimulated Culture (metaphases)
Description

PeripheralBoodCultureMetaphasePresentNumber

Data type

double

Alias
NCI Metathesaurus ObjectClass
C0229664
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Peripheral Bood, Stimulated Culture, Specify mitogen (metaphases)
Description

PeripheralBoodCultureMitogenDescriptionText

Data type

text

Alias
NCI Metathesaurus ObjectClass
C0229664
NCI Thesaurus ObjectClass
C16478
UMLS 2011AA ObjectClass
C0010453
NCI Thesaurus ObjectClass
C660
UMLS 2011AA ObjectClass
C0026249
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Peripheral Bood, Other Specify (metaphases)
Description

PeripheralBood,OtherSpecify(metaphases)

Data type

text

Peripheral Bood, Other Specify (metaphases)
Description

PeripheralBood,OtherSpecify(metaphases)

Data type

text

Total Metaphases Analyzed
Description

TotalMetaphasesAnalyzed

Data type

double

Number of Abnormal Metaphases
Description

NumberofAbnormalMetaphases

Data type

double

Number of Karotype Preparations
Description

KaryotypeCount

Data type

double

Are results adequate for banded analysis?
Description

MetaphaseAnalysisInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25391
UMLS 2011AA Property
C0936012
NCI Thesaurus ObjectClass
C16846
UMLS 2011AA ObjectClass
C0025564
Were FISH studies done?
Description

FISHInd

Data type

text

If yes, specify probes (FISH)
Description

FISHProbe

Data type

text

Total Interphase nuclei
Description

Interphases,TotalNuclei

Data type

double

Total abnormal interphases
Description

Interphases,Abnormal

Data type

double

Total metaphases
Description

FISHMetaphases,Total

Data type

double

Total abnormal metaphases
Description

FISHMetaphases,Abnormal

Data type

double

Complete karyotype description.
Description

KaryotypeDescription

Data type

text

Investigator
Description

RegisteredInvestigator

Data type

text

Date
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For Ecog Leukemia Cytogenetics Report Form
Description

Ccrr Module For Ecog Leukemia Cytogenetics Report Form

Date specimens collected
Description

Datespecimenscollected

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: ECOG Leukemia Cytogenetics Report Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOG clinical trial administrative data
CytogeneticsIdentifier
Item
Cytogeneticist
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16487 (NCI Thesaurus ObjectClass)
C0010802 (UMLS 2011AA ObjectClass)
PhoneNumber
Item
Phone No.
double
Patient'sName
Item
Patient's Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ECOGPatientID
Item
ECOG Patient Seq. No.
text
ParticipatingGroupProtocolNo.
Item
Participating Group Prot. No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID no.
text
ParticipatingGroupName
Item
Group
text
InstitutionName
Item
Institution
text
StepNo.
Item
Step No.
text
AffiliateName
Item
Affiliate
text
Item Group
Cytogenetics samples
Datesampleobtained
Item
Date sample obtained
text
Item
Is Extra material stored?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
C60824 (NCI Thesaurus Property)
C1698986 (UMLS 2011AA Property)
CL.1
Code List
Is Extra material stored?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SpecimenRemainingStorageName
Item
If yes, specify type (extra material)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
C60824 (NCI Thesaurus Property)
C1698986 (UMLS 2011AA Property)
Item Group
Number Of Metaphases
BoneMarrowMetaphasePresentNumber
Item
Bone Marrow, unsimulated short-term culture (metaphases)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
BoneMarrowDirectMetaphasePresentNumber
Item
Bone Marrow, direct preparation (metaphases)
double
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
C0439851 (NCI Metathesaurus ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
BoneMarrowCultureMetaphasePresentNumber
Item
Bone Marrow, Stimulated Culture (metaphases)
double
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
BoneMarrowCultureMitogenDescriptionText
Item
Bone Marrow, Stimulated Culture, Specify mitogen (metaphases)
text
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
C660 (NCI Thesaurus ObjectClass)
C0026249 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
BoneMarrowCultureMethodText
Item
Bone Marrow, Other Specify (metaphases)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
BoneMarrowCultureMethodText
Item
Bone Marrow, Other Specify (metaphases)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
PeripheralBloodMetaphasePresentNumber
Item
Peripheral Blood, unsimulated short-term culture (metaphases)
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C0229664 (NCI Metathesaurus ObjectClass)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
PeripheralBood,directpreparation(metaphases)
Item
Peripheral Bood, direct preparation (metaphases)
text
PeripheralBoodCultureMetaphasePresentNumber
Item
Peripheral Bood, Stimulated Culture (metaphases)
double
C0229664 (NCI Metathesaurus ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PeripheralBoodCultureMitogenDescriptionText
Item
Peripheral Bood, Stimulated Culture, Specify mitogen (metaphases)
text
C0229664 (NCI Metathesaurus ObjectClass)
C16478 (NCI Thesaurus ObjectClass)
C0010453 (UMLS 2011AA ObjectClass)
C660 (NCI Thesaurus ObjectClass)
C0026249 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
PeripheralBood,OtherSpecify(metaphases)
Item
Peripheral Bood, Other Specify (metaphases)
text
PeripheralBood,OtherSpecify(metaphases)
Item
Peripheral Bood, Other Specify (metaphases)
text
TotalMetaphasesAnalyzed
Item
Total Metaphases Analyzed
double
NumberofAbnormalMetaphases
Item
Number of Abnormal Metaphases
double
KaryotypeCount
Item
Number of Karotype Preparations
double
Item
Are results adequate for banded analysis?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25391 (NCI Thesaurus Property)
C0936012 (UMLS 2011AA Property)
C16846 (NCI Thesaurus ObjectClass)
C0025564 (UMLS 2011AA ObjectClass)
CL.2
Code List
Are results adequate for banded analysis?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Were FISH studies done?
text
CL.3
Code List
Were FISH studies done?
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
FISHProbe
Item
If yes, specify probes (FISH)
text
Interphases,TotalNuclei
Item
Total Interphase nuclei
double
Interphases,Abnormal
Item
Total abnormal interphases
double
FISHMetaphases,Total
Item
Total metaphases
double
FISHMetaphases,Abnormal
Item
Total abnormal metaphases
double
KaryotypeDescription
Item
Complete karyotype description.
text
RegisteredInvestigator
Item
Investigator
text
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Ecog Leukemia Cytogenetics Report Form
Datespecimenscollected
Item
Date specimens collected
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
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