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7257

Description

AMC-045 Hematology Form (F22) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=43C69839-22BB-1EAA-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=43C69839-22BB-1EAA-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Anal Cancer NCT00324415 Lab - AMC-045 Hematology Form (F22) - 2720666v1.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: AMC-045 Hematology Form (F22)
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Visit number
    Description

    Visit number

    Data type

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1549755
    NCI Thesaurus ObjectClass
    C16696
    NCI Thesaurus Property
    C25385
    Sequence number
    Description

    SequentialFormSubmissionCount

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS 2011AA ObjectClass
    C0376315
    NCI Thesaurus ValueDomain
    C25463
    UMLS 2011AA ValueDomain
    C0750480
    NCI Thesaurus ObjectClass-2
    C49153
    UMLS 2011AA ObjectClass-2
    C1705294
    NCI Thesaurus Property
    C25694
    UMLS 2011AA Property
    C1515022
    Date of evaluation (mm/dd/yyyy)
    Description

    Assessment Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2985720
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C38000
    Reporting Period (select one)
    Description

    Clinical Trial Period

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS CUI-1
    C2347804
    NCI Thesaurus ObjectClass
    C25214
    NCI Thesaurus Property
    C25616
    NCI Thesaurus ObjectClass-2
    C25651
    Ccrr Module For Hematology - Rf22
    Description

    Ccrr Module For Hematology - Rf22

    Hemoglobin (g/dl)
    Description

    LaboratoryProcedureHemoglobinResultSpecifiedValue

    Data type

    float

    Measurement units
    • g/dL
    Alias
    NCI Thesaurus Property
    C16676
    UMLS 2011AA Property
    C0019046
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    g/dL
    Hematocrit (%)
    Description

    LaboratoryProcedureHematocritOutcomePercentageValue

    Data type

    float

    Measurement units
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C64796
    UMLS 2011AA Property-2
    C0018935
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    %
    Peripheral WBC Count (1000/mm^3)
    Description

    Leukocytes (WBC)

    Data type

    float

    Measurement units
    • 1000/uL
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C0023508
    NCI Thesaurus Property
    C12529
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus ValueDomain
    C25712
    NCI Thesaurus ValueDomain-2
    C38024
    1000/uL
    Peripheral Neutrophil Count (1000/mm^3 WBC x % Neutrophils including Bands/100)
    Description

    LaboratoryProcedureNeutrophilResultSpecifiedValue

    Data type

    float

    Measurement units
    • 1000/uL
    Alias
    NCI Thesaurus Property
    C12533
    UMLS 2011AA Property
    C0027950
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    1000/uL
    Peripheral Lymphocytes (%) (%)
    Description

    LaboratoryProcedureLymphocyteOutcomePercentageValue

    Data type

    float

    Measurement units
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C12535
    UMLS 2011AA Property
    C0024264
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    %
    Peripheral Monocytes (%) (%)
    Description

    LaboratoryProcedureMonocyteResultPercentageValue

    Data type

    float

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C12547
    UMLS 2011AA Property
    C0026473
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    Peripheral Eosinophils (%) (%)
    Description

    LaboratoryProcedureEosinophilResultPercentageValue

    Data type

    float

    Measurement units
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C12532
    UMLS 2011AA Property-2
    C0014467
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    %
    Peripheral Basophils (%) (%)
    Description

    LaboratoryProcedureBasophilResultPercentageValue

    Data type

    float

    Measurement units
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C12531
    UMLS 2011AA Property-2
    C0004827
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    %
    Other, specify test (Hematology)
    Description

    LaboratoryProcedureSecondOptionalPerformedSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus Property-2
    C25666
    UMLS 2011AA Property-2
    C0205436
    NCI Thesaurus Property-3
    C25603
    UMLS 2011AA Property-3
    C1518600
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Other, specify test (Hematology)
    Description

    LaboratoryProcedureSecondOptionalPerformedSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus Property-2
    C25666
    UMLS 2011AA Property-2
    C0205436
    NCI Thesaurus Property-3
    C25603
    UMLS 2011AA Property-3
    C1518600
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Other specify value
    Description

    LaboratoryProcedurePerformedValue

    Data type

    float

    Alias
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    Other specify value
    Description

    LaboratoryProcedurePerformedValue

    Data type

    float

    Alias
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    Peripheral Platelet Count (1000/mm^3)
    Description

    Platelets

    Data type

    float

    Measurement units
    • 1000/uL
    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0005821
    NCI Thesaurus Property-2
    C12520
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25712
    1000/uL
    Units (other specify test)
    Description

    AssessmentLabUOM

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C20989
    UMLS 2011AA ObjectClass
    C0031809
    NCI Thesaurus Property
    C37984
    UMLS 2011AA Property
    C0022877
    NCI Thesaurus ValueDomain
    C25709
    UMLS 2011AA ValueDomain
    C1519795
    Comments
    Description

    Comments

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: AMC-045 Hematology Form (F22)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header Module
    Visit number
    Item
    Visit number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C1549755 (UMLS CUI-1)
    C16696 (NCI Thesaurus ObjectClass)
    C25385 (NCI Thesaurus Property)
    SequentialFormSubmissionCount
    Item
    Sequence number
    float
    C19464 (NCI Thesaurus ObjectClass)
    C0376315 (UMLS 2011AA ObjectClass)
    C25463 (NCI Thesaurus ValueDomain)
    C0750480 (UMLS 2011AA ValueDomain)
    C49153 (NCI Thesaurus ObjectClass-2)
    C1705294 (UMLS 2011AA ObjectClass-2)
    C25694 (NCI Thesaurus Property)
    C1515022 (UMLS 2011AA Property)
    Assessment Date
    Item
    Date of evaluation (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2985720 (UMLS CUI-1)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C38000 (NCI Thesaurus Property)
    Item
    Reporting Period (select one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C2347804 (UMLS CUI-1)
    C25214 (NCI Thesaurus ObjectClass)
    C25616 (NCI Thesaurus Property)
    C25651 (NCI Thesaurus ObjectClass-2)
    CL.1
    Code List
    Reporting Period (select one)
    CL Item
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    CL Item
    On Treatment (On treatment)
    CL Item
    Post-therapy (Post therapy)
    C54735 (NCI Thesaurus)
    C1882428 (UMLS 2011AA)
    Item Group
    Ccrr Module For Hematology - Rf22
    LaboratoryProcedureHemoglobinResultSpecifiedValue
    Item
    Hemoglobin (g/dl)
    float
    C16676 (NCI Thesaurus Property)
    C0019046 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    LaboratoryProcedureHematocritOutcomePercentageValue
    Item
    Hematocrit (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C64796 (NCI Thesaurus Property-2)
    C0018935 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    Leukocytes (WBC)
    Item
    Peripheral WBC Count (1000/mm^3)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0023508 (UMLS CUI-1)
    C12529 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C38024 (NCI Thesaurus ValueDomain-2)
    LaboratoryProcedureNeutrophilResultSpecifiedValue
    Item
    Peripheral Neutrophil Count (1000/mm^3 WBC x % Neutrophils including Bands/100)
    float
    C12533 (NCI Thesaurus Property)
    C0027950 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    LaboratoryProcedureLymphocyteOutcomePercentageValue
    Item
    Peripheral Lymphocytes (%) (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C12535 (NCI Thesaurus Property)
    C0024264 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    LaboratoryProcedureMonocyteResultPercentageValue
    Item
    Peripheral Monocytes (%) (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C12547 (NCI Thesaurus Property)
    C0026473 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    LaboratoryProcedureEosinophilResultPercentageValue
    Item
    Peripheral Eosinophils (%) (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C12532 (NCI Thesaurus Property-2)
    C0014467 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    LaboratoryProcedureBasophilResultPercentageValue
    Item
    Peripheral Basophils (%) (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C12531 (NCI Thesaurus Property-2)
    C0004827 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    LaboratoryProcedureSecondOptionalPerformedSpecify
    Item
    Other, specify test (Hematology)
    text
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C25666 (NCI Thesaurus Property-2)
    C0205436 (UMLS 2011AA Property-2)
    C25603 (NCI Thesaurus Property-3)
    C1518600 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    LaboratoryProcedureSecondOptionalPerformedSpecify
    Item
    Other, specify test (Hematology)
    text
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C25666 (NCI Thesaurus Property-2)
    C0205436 (UMLS 2011AA Property-2)
    C25603 (NCI Thesaurus Property-3)
    C1518600 (UMLS 2011AA Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    LaboratoryProcedurePerformedValue
    Item
    Other specify value
    float
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    LaboratoryProcedurePerformedValue
    Item
    Other specify value
    float
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    Platelets
    Item
    Peripheral Platelet Count (1000/mm^3)
    float
    C20200 (NCI Thesaurus Property)
    C0005821 (UMLS CUI-1)
    C12520 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    AssessmentLabUOM
    Item
    Units (other specify test)
    text
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C37984 (NCI Thesaurus Property)
    C0022877 (UMLS 2011AA Property)
    C25709 (NCI Thesaurus ValueDomain)
    C1519795 (UMLS 2011AA ValueDomain)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
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