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6469

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CALGB: 10603 Concomitant Medications Form Daunorubicin, Cytarabine, and Midostaurin in Treating Patients With Newly Diagnosed Acute Myeloid Leukemia NCT00651261 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=742F65D1-34F2-9883-E040-BB89AD437120

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=742F65D1-34F2-9883-E040-BB89AD437120

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2014-12-29 2014-12-29 - Martin Dugas
  3. 2017-07-14 2017-07-14 - Martin Dugas
Uppladdad den

29 december 2014

DOI

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Creative Commons BY-NC 3.0

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    Concomitant Medications Form (CALGB 10603)

    INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

    Administrative documentation
    Beskrivning

    Administrative documentation

    Alias
    UMLS CUI-1
    C1320722
    CALGB Form
    Beskrivning

    Form ID CALGB

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C19464
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass-2
    C25442
    UMLS CUI-1
    C3262252
    UMLS CUI-2
    C1516238
    CALGB Study No
    Beskrivning

    Protocol ID CALGB

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C25320
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    UMLS CUI-1
    C3274381
    UMLS CUI-2
    C1516238
    CALGB Patient ID
    Beskrivning

    Trial subject ID CALGB

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    Treatment Reporting Period Start Date
    Beskrivning

    Reporting Period Start Date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25616
    NCI Thesaurus Property-2
    C25651
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS CUI-1
    C2361257
    Treatment Reporting Period End Date
    Beskrivning

    Reporting Period End Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property-2
    C25651
    UMLS CUI-1
    C2361259
    Are data amended
    Beskrivning

    Data amended

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    UMLS CUI-1
    C0680532
    Patient Initials (Last, First Middle)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    UMLS CUI-1
    C2986440
    Patient Hospital No.
    Beskrivning

    Medical Record Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25261
    NCI Thesaurus Property-2
    C25198
    UMLS CUI-1
    C1301894
    Institution/Affiliate
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Participating Group
    Beskrivning

    Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    UMLS CUI-1
    C2347449
    Participating Group Study No
    Beskrivning

    Study Number Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C25320
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    UMLS CUI-1
    C3274381
    UMLS CUI-2
    C2347449
    Participating Group Patient ID
    Beskrivning

    Trial subject ID Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    UMLS CUI-1
    C2348585
    UMLS CUI-2
    C2347449
    Page (___ of ___)
    Beskrivning

    Additional Form Page Number

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19464
    NCI Thesaurus ObjectClass-2
    C25406
    NCI Thesaurus Property
    C25695
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ValueDomain-2
    C42783
    UMLS CUI-1
    C1706499
    UMLS CUI-2
    C1704732
    UMLS CUI-3
    C0237753
    Concomitant medication
    Beskrivning

    Concomitant medication

    Alias
    UMLS CUI-1
    C2347852
    Concomitant Medication
    Beskrivning

    Concomitant Medication

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2347852
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus Property
    C25639
    NCI Thesaurus ObjectClass-2
    C25730
    Medication Category
    Beskrivning

    Concomitant Medication Category

    Datatyp

    integer

    Alias
    NCI Thesaurus ValueDomain
    C25372
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus ObjectClass-2
    C25730
    NCI Thesaurus Property
    C25382
    UMLS CUI-1
    C2826808
    CYP3A4 inhibitor/inducer
    Beskrivning

    CYP3A4 inhibitor or inducer

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus ObjectClass-2
    C61367
    NCI Thesaurus ObjectClass-3
    C17573
    NCI Thesaurus ObjectClass-4
    C42791
    NCI Thesaurus Property
    C25409
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C3830624
    UMLS CUI-2
    C3830625
    Agent Total Dose (per day)
    Beskrivning

    Concomitant Medication Daily Dose

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C25473
    UMLS CUI-1
    C2826638
    NCI Thesaurus ObjectClass-2
    C1708
    NCI Thesaurus Property
    C25304
    NCI Thesaurus Property-2
    C25256
    NCI Thesaurus ValueDomain
    C25488
    NCI Thesaurus ValueDomain-2
    C1708
    Units
    Beskrivning

    Units

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C1519795
    NCI Thesaurus ValueDomain-2
    C44278
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus Property
    C25256
    Start date
    Beskrivning

    Concomitant Medication Start Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus Property
    C25275
    UMLS CUI-1
    C2826734
    Stop date (or)
    Beskrivning

    Concomitant Medication End Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C1708
    NCI Thesaurus Property
    C25275
    UMLS CUI-1
    C2826744
    Ongoing
    Beskrivning

    Concomitant Medication Ongoing

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C459
    NCI Thesaurus ObjectClass-2
    C25730
    NCI Thesaurus Property
    C25471
    NCI Thesaurus Property-2
    C25409
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2826666

    Similar models

    INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Administrative documentation
    C1320722 (UMLS CUI-1)
    Form ID CALGB
    Item
    CALGB Form
    text
    C25337 (NCI Thesaurus ValueDomain)
    C19464 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus ObjectClass-2)
    C3262252 (UMLS CUI-1)
    C1516238 (UMLS CUI-2)
    Protocol ID CALGB
    Item
    CALGB Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    C3274381 (UMLS CUI-1)
    C1516238 (UMLS CUI-2)
    Trial subject ID CALGB
    Item
    CALGB Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    Reporting Period Start Date
    Item
    Treatment Reporting Period Start Date
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C25651 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C2361257 (UMLS CUI-1)
    Reporting Period End Date
    Item
    Treatment Reporting Period End Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25616 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    C25651 (NCI Thesaurus Property-2)
    C2361259 (UMLS CUI-1)
    Data amended
    Item
    Are data amended
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    C0680532 (UMLS CUI-1)
    Patient Initials
    Item
    Patient Initials (Last, First Middle)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    C2986440 (UMLS CUI-1)
    Medical Record Number
    Item
    Patient Hospital No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    C1301894 (UMLS CUI-1)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Participating Group
    Item
    Participating Group
    text
    C25191 (NCI Thesaurus ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C2347449 (UMLS CUI-1)
    Study Number Participating Group
    Item
    Participating Group Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    C3274381 (UMLS CUI-1)
    C2347449 (UMLS CUI-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    C2348585 (UMLS CUI-1)
    C2347449 (UMLS CUI-2)
    Additional Form Page Number
    Item
    Page (___ of ___)
    text
    C19464 (NCI Thesaurus ObjectClass)
    C25406 (NCI Thesaurus ObjectClass-2)
    C25695 (NCI Thesaurus Property)
    C25337 (NCI Thesaurus ValueDomain)
    C42783 (NCI Thesaurus ValueDomain-2)
    C1706499 (UMLS CUI-1)
    C1704732 (UMLS CUI-2)
    C0237753 (UMLS CUI-3)
    Item Group
    Concomitant medication
    C2347852 (UMLS CUI-1)
    Concomitant Medication
    Item
    Concomitant Medication
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2347852 (UMLS CUI-1)
    C459 (NCI Thesaurus ObjectClass)
    C25639 (NCI Thesaurus Property)
    C25730 (NCI Thesaurus ObjectClass-2)
    Item
    Medication Category
    integer
    C25372 (NCI Thesaurus ValueDomain)
    C459 (NCI Thesaurus ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C2826808 (UMLS CUI-1)
    Code List
    Medication Category
    CL Item
    Antibiotic/antiviral/antifungal (1)
    CL Item
    Antiemetic (2)
    CL Item
    Antihistamine (3)
    CL Item
    Corticosteroid (4)
    CL Item
    Diuretic/antihypertensive (5)
    CL Item
    Growth Factor (6)
    CL Item
    Nsaid/opioid (7)
    CL Item
    Proton Pump Inhibitor/h2 Antagonist (8)
    CL Item
    Other (9)
    CYP3A4 inhibitor or inducer
    Item
    CYP3A4 inhibitor/inducer
    boolean
    C459 (NCI Thesaurus ObjectClass)
    C61367 (NCI Thesaurus ObjectClass-2)
    C17573 (NCI Thesaurus ObjectClass-3)
    C42791 (NCI Thesaurus ObjectClass-4)
    C25409 (NCI Thesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C3830624 (UMLS CUI-1)
    C3830625 (UMLS CUI-2)
    Concomitant Medication Daily Dose
    Item
    Agent Total Dose (per day)
    float
    C25473 (NCI Thesaurus ObjectClass)
    C2826638 (UMLS CUI-1)
    C1708 (NCI Thesaurus ObjectClass-2)
    C25304 (NCI Thesaurus Property)
    C25256 (NCI Thesaurus Property-2)
    C25488 (NCI Thesaurus ValueDomain)
    C1708 (NCI Thesaurus ValueDomain-2)
    Units
    Item
    Units
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1519795 (UMLS CUI-1)
    C44278 (NCI Thesaurus ValueDomain-2)
    C1708 (NCI Thesaurus ObjectClass)
    C25256 (NCI Thesaurus Property)
    Concomitant Medication Start Date
    Item
    Start date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C1708 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2826734 (UMLS CUI-1)
    Concomitant Medication End Date
    Item
    Stop date (or)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1708 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2826744 (UMLS CUI-1)
    Concomitant Medication Ongoing
    Item
    Ongoing
    boolean
    C459 (NCI Thesaurus ObjectClass)
    C25730 (NCI Thesaurus ObjectClass-2)
    C25471 (NCI Thesaurus Property)
    C25409 (NCI Thesaurus Property-2)
    C25704 (NCI Thesaurus ValueDomain)
    C2826666 (UMLS CUI-1)

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