Form Completion Date
Item
Date form originally completed (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Amendment date
Item
Date form amended (m d y)
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0680532 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Person Amending Form
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
C1547383 (UMLS CUI-2)
Patient Initials
Item
Patient Initials (First, Middle, Last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID GOG
Item
Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25521 (NCI Thesaurus Property-2)
C2348585 (UMLS CUI-1)
C1512288 (UMLS CUI-2)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Cycle Number Chemotherapeutics
Item
Current Cycle Number
integer
C25337 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property-2)
Item
Has the patient received any transfusions during this course of therapy?
text
C25180 (NCI Thesaurus ValueDomain)
C15366 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1879316 (UMLS CUI-1)
Code List
Has the patient received any transfusions during this course of therapy?
CL Item
No Transfusion (No)
CL Item
Transfusion With Red Blood Cells (Yes, red blood cells)
CL Item
Transfusion With Platelets (Yes, platelets)
Hospitalization
Item
Was patient hospitalized as a result of reported adverse events?
boolean
C38148 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25182 (NCI Thesaurus ObjectClass-2)
C25385 (NCI Thesaurus Property)
C0019993 (UMLS CUI-1)
Cytokine Therapy
Item
Were cytokines administered this course?
boolean
C38148 (NCI Thesaurus ValueDomain)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0199974 (UMLS CUI-1)
Cytokine Therapy, specify
Item
Yes specify
text
C25685 (NCI Thesaurus ValueDomain)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0199974 (UMLS CUI-1)
WBC done
Item
Peripheral WBC count done
boolean
C38148 (NCI Thesaurus ValueDomain)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0023508 (UMLS CUI-1)
Leukocytes (WBC)
Item
Peripheral WBC count (1000/mm3)
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)
WBC date
Item
WBC Date
date
C25164 (NCI Thesaurus ValueDomain)
C12529 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0023508 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
CTC Adverse Event Grade
Item
CTC Adverse Event Grade
integer
C49704 (NCI Thesaurus ObjectClass)
C18000 (NCI Thesaurus ValueDomain)
C25365 (NCI Thesaurus Property)
C2985911 (UMLS CUI-1)
Item
CTC Adverse Event Attribution Scale
integer
C25664 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25358 (NCI Thesaurus Property)
C1706735 (UMLS CUI-1)
Code List
CTC Adverse Event Attribution Scale
SAE report
Item
SAE report submitted
boolean
C38148 (NCI Thesaurus ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C25375 (NCI Thesaurus Property)
C54035 (NCI Thesaurus ObjectClass-2)
C1519255 (UMLS CUI-1)
C0684224 (UMLS CUI-2)
ANC
Item
Peripheral ANC/Granulocytes count done
boolean
C25294 (NCI Thesaurus ObjectClass)
C20200 (NCI Thesaurus Property)
C12530 (NCI Thesaurus Property-2)
C63321 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C0948762 (UMLS CUI-1)
Granulocyte count
Item
Peripheral Granulocytes count (ANC/ 1000/mm3)
float
C20200 (NCI Thesaurus Property)
C0857490 (UMLS CUI-1)
C12530 (NCI Thesaurus Property-2)
C25463 (NCI Thesaurus ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
Neutrophils date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C12533 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0200633 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Platelets
Item
Peripheral Platelet count done
boolean
C38148 (NCI Thesaurus ValueDomain)
C20200 (NCI Thesaurus Property)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0005821 (UMLS CUI-1)
Platelets
Item
Peripheral Platelet count (mm3)
float
C20200 (NCI Thesaurus Property)
C0005821 (UMLS CUI-1)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
Platelets date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0005821 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C12520 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
Hemoglobin
Item
Hemoglobin done
boolean
C38148 (NCI Thesaurus ValueDomain)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0019046 (UMLS CUI-1)
Hemoglobin
Item
Hemoglobin
float
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C0019046 (UMLS CUI-1)
Hemoglobin Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C16676 (NCI Thesaurus Property)
C20200 (NCI Thesaurus Property-2)
C25294 (NCI Thesaurus ObjectClass)
C0019046 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
CTC Adverse Event Term
Item
CTC Adverse Event Term
text
C25284 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C45559 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C2826934 (UMLS CUI-2)
CTC Adverse Event Reported Term
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25161 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C2699044 (UMLS CUI-2)
Adverse Event Onset Date
Item
Adverse Event Onset Date
date
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C49704 (NCI Thesaurus ObjectClass)
C25279 (NCI Thesaurus Property)
C2985916 (UMLS CUI-1)
Item
AE Present Status
text
C25626 (NCI Thesaurus Property)
C41331 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C1705586 (UMLS CUI-1)
Code List
AE Present Status
CL Item
Fatal Or Died (Fatal/Died)
CL Item
Intervention For Adverse Event Continues (Intervention for AE Continues)
CL Item
Not Recovered Or Not Resolved (Not recovered/Not resolved)
C49494 (NCI Thesaurus)
C1709277 (UMLS 2011AA)
CL Item
Recovered Or Resolved With Sequelae (Recovered/Resolved with Sequelae)
C49495 (NCI Thesaurus)
C1709862 (UMLS 2011AA)
CL Item
Recovered Or Resolved Without Sequelae (Recovered/Resolved without Sequelae)
C85257 (NCI Thesaurus)
C2827606 (UMLS 2011AA)
CL Item
Recovering Or Resolving (Recovering/Resolving)
C49496 (NCI Thesaurus)
C1709864 (UMLS 2011AA)
Item
The CTCAE data entered above is
text
C25284 (NCI Thesaurus ValueDomain)
C49704 (NCI Thesaurus ObjectClass)
C25714 (NCI Thesaurus Property)
C1516728 (UMLS CUI-1)
C0333052 (UMLS CUI-2)
Code List
The CTCAE data entered above is
CL Item
Version 2 (version 2)
CL Item
Version 3 (version 3)