ID

7607

Description

ANHL01P1: Eligibility Worksheet Rituximab, Rasburicase, and Combination Chemotherapy in Treating Young Patients With Newly Diagnosed Advanced B-Cell Leukemia or Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9F4CEB9-15F1-2736-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B9F4CEB9-15F1-2736-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Drug/Agent Toxicity by Tissue/Organ NCT00057811 Eligibility - ANHL01P1: Eligibility Worksheet - 2091107v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: ANHL01P1: Eligibility Worksheet
    1. No Instruction available.
Header
Description

Header

Institution
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Name
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Study Number
Description

Protocol ID COG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1516477
NCI Thesaurus Property
C25364
COG Number
Description

PatientCOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C39353
UMLS 2011AA Property-2
C1516477
Patient Name
Description

PatientName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Today's date
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
Date worksheet entered into RDE
Description

DataEnteredDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C37949
UMLS 2011AA Property
C1521975
Unnamed2
Description

Unnamed2

Does patient have newly diagnosed mature (CD20 positive) high-grade B-lineage lymphoma, i.e. diffuse large B-Cell Lymphoma, Burkitt's lymphoma or Burkitt's-like lymphoma? (Answer must be yes. If answer is 'no', terminate registration process.)
Description

B-lineageLymphomaDiagnosisInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C3208
UMLS 2011AA ObjectClass
C0024299
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Does patient have pre-cursor B-cell lymphoblastic lymphoma? (Answer must be no. If answer is 'yes', terminate registration process.)
Description

B-cellLymphomaDiagnosisInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C3208
UMLS 2011AA ObjectClass
C0024299
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Is patient >= 1 year and <30 years at study enrollment? (Answer must be yes. If answer is 'no', terminate registration process.)
Description

PatientRequiredAgeInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25652
UMLS 2011AA Property
C1514873
NCI Thesaurus Property-2
C25150
UMLS 2011AA Property-2
C0001779
Did patient receive any previous chemotherapy prior to registration? (Answer must be no. If yes, terminate registration process.)
Description

PriorChemotherapyAdministeredInd-3

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Did patient receive emergency irradiation and/or steroid therapy, prior to registration? (If yes, the following 3 questions must be answered.)
Description

EmergencyTherapyAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Will the patient start protocol therapy within 72 hours of emergency treatment? (Only required if patient received emergency treatment. Then the answer must be yes, or the registration process must be terminated.)
Description

ProtocolTherapyBeginTimeInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Were steroids given? (Can be yes or no)
Description

SteroidTherapyAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Metathesaurus ObjectClass
C0149783
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
were bone marrow and CSF exams obtained prior to steroids? (Required only if answer to question above is yes. Must be yes or N/A. If no, terminate registration process.)
Description

BoneMarrowPre-StudyEvaluationInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus ObjectClass
C12431
UMLS 2011AA ObjectClass
C0005953
NCI Thesaurus Property-2
C38010
UMLS 2011AA Property-2
C1527048
Did the patient receive corticosteroids for more than 10 days and/or the patient receive corticosteroids within 8 days from diagnosis and initial work-up?
Description

CorticosteroidAdministeredInd

Data type

text

Alias
NCI Thesaurus Property
C25629
UMLS 2011AA Property
C0332152
NCI Thesaurus ObjectClass
C2322
UMLS 2011AA ObjectClass
C0001617
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Did the patient receive any steroids, other than corticosteroids, in the week prior to diagnosis? (To be eligible, patient must not have received any steroids except in emergency situation, as noted above 8 days prior to diagnosis.)
Description

SteroidTherapyDiagnosisAdministeredInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Metathesaurus ObjectClass
C0149783
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Karnofsky Performance Score (For patients greater than 10 years of age)
Description

KarnofskyPerformanceStatusScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C28013
UMLS 2011AA ObjectClass
C0206065
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Lansky Play Score (For patients less than or equal to 10 years of age)
Description

LanskyPerformanceStatusScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ObjectClass
C25361
UMLS 2011AA ObjectClass
C0597198
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has patient had any prior solid organ transplantation? (Must be no. If yes, terminate registration process.)
Description

TransplantReceivedInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C12981
UMLS 2011AA ObjectClass
C0332835
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
Does patient have G6PD deficiency? (Can be yes or no)
Description

G6PDEnzymeDeficiencyInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Does patient have a congenital or acquired immune deficiency?
Description

ImmuneDeficiencyInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Murphy Stage (Institution must pick one.)
Description

MurphyStage

Data type

text

Therapy Stratification (If Group A is chosen, patient is not eligible, terminate registration process.)
Description

StudyStratificationText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15206
UMLS 2011AA ObjectClass
C0008972
NCI Thesaurus Property
C25689
UMLS 2011AA Property
C1514983
was pregnancy test obtained? (If post-menarchal female,)
Description

PatientPregnancyTestInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
is patient pregnant and/or breastfeeding? (If post-menarchal female,)
Description

PatientPregnancyInd

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25742
UMLS 2011AA Property
C0032961
has patient agreed to use contraceptive during protocol? (If patient is of reproductive potential,)
Description

ContraceptionAgreementInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C37932
UMLS 2011AA ObjectClass
C0700589
NCI Thesaurus Property
C25369
UMLS 2011AA Property
C0680240
Have patient and/or their parents or legal guardians signed a written informed consent? (To be eligible, all patients and/or parents or legal guardians must have signed a written informed consent.)
Description

InformedConsentFormSignedDate

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C16468
UMLS 2011AA ObjectClass
C0009797
NCI Thesaurus Property
C25679
Date of Start Treatment (NOTE: If the study does not have a start date e.g., a biology study, then enter in the current date, or if entering on AADM01P1, enter consent date.)
Description

Treatment Begin Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25631
NCI Thesaurus Property
C25431
UMLS CUI-1
C3173309
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
COMMENTS
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Ccrr Module For Anhl01p1: Eligibility Worksheet
Description

Ccrr Module For Anhl01p1: Eligibility Worksheet

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1 forms
  1. StudyEvent: ANHL01P1: Eligibility Worksheet
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Institution Name
Item
Institution
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Person Completing Form
Item
Name
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Protocol ID COG
Item
Study Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516477 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
PatientCOGIdentifierNumber
Item
COG Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)
PatientName
Item
Patient Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Form Completion Date
Item
Today's date
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)
DataEnteredDate
Item
Date worksheet entered into RDE
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C37949 (NCI Thesaurus Property)
C1521975 (UMLS 2011AA Property)
Item Group
Unnamed2
B-lineageLymphomaDiagnosisInd-2
Item
Does patient have newly diagnosed mature (CD20 positive) high-grade B-lineage lymphoma, i.e. diffuse large B-Cell Lymphoma, Burkitt's lymphoma or Burkitt's-like lymphoma? (Answer must be yes. If answer is 'no', terminate registration process.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3208 (NCI Thesaurus ObjectClass)
C0024299 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
B-cellLymphomaDiagnosisInd-2
Item
Does patient have pre-cursor B-cell lymphoblastic lymphoma? (Answer must be no. If answer is 'yes', terminate registration process.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3208 (NCI Thesaurus ObjectClass)
C0024299 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
PatientRequiredAgeInd-2
Item
Is patient >= 1 year and <30 years at study enrollment? (Answer must be yes. If answer is 'no', terminate registration process.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
C25150 (NCI Thesaurus Property-2)
C0001779 (UMLS 2011AA Property-2)
PriorChemotherapyAdministeredInd-3
Item
Did patient receive any previous chemotherapy prior to registration? (Answer must be no. If yes, terminate registration process.)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
EmergencyTherapyAdministeredInd-2
Item
Did patient receive emergency irradiation and/or steroid therapy, prior to registration? (If yes, the following 3 questions must be answered.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
ProtocolTherapyBeginTimeInd-2
Item
Will the patient start protocol therapy within 72 hours of emergency treatment? (Only required if patient received emergency treatment. Then the answer must be yes, or the registration process must be terminated.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
SteroidTherapyAdministeredInd-2
Item
Were steroids given? (Can be yes or no)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0149783 (NCI Metathesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
were bone marrow and CSF exams obtained prior to steroids? (Required only if answer to question above is yes. Must be yes or N/A. If no, terminate registration process.)
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C12431 (NCI Thesaurus ObjectClass)
C0005953 (UMLS 2011AA ObjectClass)
C38010 (NCI Thesaurus Property-2)
C1527048 (UMLS 2011AA Property-2)
CL.8
Code List
were bone marrow and CSF exams obtained prior to steroids? (Required only if answer to question above is yes. Must be yes or N/A. If no, terminate registration process.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
N/A (N/A)
Item
Did the patient receive corticosteroids for more than 10 days and/or the patient receive corticosteroids within 8 days from diagnosis and initial work-up?
text
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C2322 (NCI Thesaurus ObjectClass)
C0001617 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
CL.9
Code List
Did the patient receive corticosteroids for more than 10 days and/or the patient receive corticosteroids within 8 days from diagnosis and initial work-up?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
N/a (N/A)
SteroidTherapyDiagnosisAdministeredInd-2
Item
Did the patient receive any steroids, other than corticosteroids, in the week prior to diagnosis? (To be eligible, patient must not have received any steroids except in emergency situation, as noted above 8 days prior to diagnosis.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0149783 (NCI Metathesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Karnofsky Performance Score (For patients greater than 10 years of age)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C28013 (NCI Thesaurus ObjectClass)
C0206065 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.11
Code List
Karnofsky Performance Score (For patients greater than 10 years of age)
CL Item
100 (Normal, no complaints, no evidence of disease)
CL Item
90 (Able to carry on normal activity, minor signs or symptoms of disease)
CL Item
80 (Normal activity with effort, some signs or symptoms of disease)
CL Item
70 (Cares for self. Unable to carry on normal activity or to do active work)
CL Item
60 (Requires occasional assistance, but is able to care for most of own needs)
CL Item
50 (Requires considerable assistance and frequent medical care)
CL Item
40 (Disabled, requires special care and assistance)
CL Item
30 (Severely disabled, hospitalization is indicated although death is not imminent)
CL Item
20 (Hospitalization necessary, very sick, active supportive treatment necessary)
CL Item
10 (Moribund, fatal processes progressing rapidly)
CL Item
0 (Dead)
C0919414 (NCI Metathesaurus)
Item
Lansky Play Score (For patients less than or equal to 10 years of age)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25361 (NCI Thesaurus ObjectClass)
C0597198 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.12
Code List
Lansky Play Score (For patients less than or equal to 10 years of age)
CL Item
100 (Fully active, normal)
CL Item
90 (Minor restrictions in physically strenuous activity)
CL Item
80 (Active, but tires more quickly)
CL Item
70 (Both greater restriction of and less time spent in play activity)
CL Item
60 (Up and around, but minimal active play; keeps busy with quieter activities)
CL Item
50 (Gets dressed but lies around much of the day, no active play, able to participate in all quiet play and activities)
CL Item
40 (Mostly in bed; participates in quiet activities)
CL Item
30 (In bed; needs assistance even for quiet play)
CL Item
20 (Often sleeping; play entirely limited to very passive activities)
CL Item
10 (No play; does not get out of bed)
CL Item
0 (Unresponsive)
C0919414 (NCI Metathesaurus)
TransplantReceivedInd-2
Item
Has patient had any prior solid organ transplantation? (Must be no. If yes, terminate registration process.)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C12981 (NCI Thesaurus ObjectClass)
C0332835 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
G6PDEnzymeDeficiencyInd-2
Item
Does patient have G6PD deficiency? (Can be yes or no)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
ImmuneDeficiencyInd-2
Item
Does patient have a congenital or acquired immune deficiency?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Murphy Stage (Institution must pick one.)
text
CL.16
Code List
Murphy Stage (Institution must pick one.)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
Item
Therapy Stratification (If Group A is chosen, patient is not eligible, terminate registration process.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15206 (NCI Thesaurus ObjectClass)
C0008972 (UMLS 2011AA ObjectClass)
C25689 (NCI Thesaurus Property)
C1514983 (UMLS 2011AA Property)
CL.17
Code List
Therapy Stratification (If Group A is chosen, patient is not eligible, terminate registration process.)
CL Item
Group A: Completely resected Murphy stage I disease (any site) (Group A: Completely resected Murphy stage I disease (any site))
CL Item
Group A: Completely resected abdominal Murphy stage II lesions (Group A: Completely resected abdominal Murphy stage II lesions)
CL Item
Group B: Not eligible for Group A or Group C (Group B: Not eligible for Group A or Group C)
CL Item
Group C: any CNS or bone marrow involvement >=25% blasts. (Group C: any CNS or bone marrow involvement >=25% blasts.)
Item
was pregnancy test obtained? (If post-menarchal female,)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
CL.18
Code List
was pregnancy test obtained? (If post-menarchal female,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
N/A, not post-menarchal, or patient is male (N/A, not post-menarchal, or patient is male)
CL Item
N/a, Patient Is Female, But Not Post-menarchal (N/A, patient is female, but not post-menarchal)
CL Item
N/a, Patient Is Male (N/A, patient is male)
Item
is patient pregnant and/or breastfeeding? (If post-menarchal female,)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
CL.19
Code List
is patient pregnant and/or breastfeeding? (If post-menarchal female,)
CL Item
No (No)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
N/A (N/A)
CL Item
No, And Not Nursing (no, and not nursing)
CL Item
No, But Nursing (no, but nursing)
Item
has patient agreed to use contraceptive during protocol? (If patient is of reproductive potential,)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C37932 (NCI Thesaurus ObjectClass)
C0700589 (UMLS 2011AA ObjectClass)
C25369 (NCI Thesaurus Property)
C0680240 (UMLS 2011AA Property)
CL.20
Code List
has patient agreed to use contraceptive during protocol? (If patient is of reproductive potential,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
InformedConsentFormSignedDate
Item
Have patient and/or their parents or legal guardians signed a written informed consent? (To be eligible, all patients and/or parents or legal guardians must have signed a written informed consent.)
boolean
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16468 (NCI Thesaurus ObjectClass)
C0009797 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)
Treatment Begin Date
Item
Date of Start Treatment (NOTE: If the study does not have a start date e.g., a biology study, then enter in the current date, or if entering on AADM01P1, enter consent date.)
date
C15368 (NCI Thesaurus ObjectClass)
C25631 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
Research Comments
Item
COMMENTS
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Ccrr Module For Anhl01p1: Eligibility Worksheet
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