ID
10095
Description
E2905 Hematology Form Lenalidomide With or Without Epoetin Alfa in Treating Patients With Myelodysplastic Syndrome and Anemia NCT00843882 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11427DB4-3795-240D-E044-0003BA3F9857
Link
Keywords
Versions (5)
- 9/19/12 9/19/12 -
- 1/8/15 1/8/15 - Martin Dugas
- 1/9/15 1/9/15 - Martin Dugas
- 1/9/15 1/9/15 - Martin Dugas
- 3/27/15 3/27/15 - Martin Dugas
Uploaded on
March 27, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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MDS Hematology Form NCT00843882
INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files
Description
ON/Off TREATMENT
Description
Cycle number
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C2045829
- NCI Thesaurus Property
- C25214
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ObjectClass
- C15368
Description
Chemotherapy cycle
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25214
- UMLS CUI-1
- C1302181
- NCI Thesaurus Property-2
- C25616
- NCI Thesaurus ValueDomain
- C25685
- NCI Thesaurus ValueDomain-2
- C25472
- NCI Thesaurus ValueDomain-3
- C25275
Description
PersonOff-TreatmentTimePeriodType
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- NCI Thesaurus Property
- C25616
- NCI Thesaurus Property-2
- C25601
- NCI Thesaurus Property-3
- C25207
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0027361
- UMLS CUI-2
- C1948053
- UMLS CUI-3
- C1518544
- UMLS CUI-4
- C0040223
- UMLS CUI-5
- C0332307
Description
Pre-registration Hematology/chemistry
Description
HematologySpecimenCollectedDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ObjectClass
- C16673
- NCI Thesaurus ObjectClass-2
- C19157
- NCI Thesaurus Property
- C25452
- UMLS CUI-1
- C1317250
Description
Test not done (Please mark "X" in Box only if test not done)
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25704
- NCI Thesaurus Property
- C25594
- NCI Thesaurus Property-2
- C38000
- NCI Thesaurus ObjectClass
- C25294
- UMLS CUI-1
- C0022885
- UMLS CUI-2
- C0445106
Description
LaboratoryProcedureGranulocyteResultLowerLimitofNormalCount
Data type
float
Measurement units
- /mm^3
Alias
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus Property
- C20200
- NCI Thesaurus Property-2
- C12530
- NCI Thesaurus ValueDomain
- C25463
- NCI Thesaurus ValueDomain-2
- C25555
- UMLS CUI-1
- C0857490
- UMLS CUI-2
- C1518030
Description
Peripheral Granulocytes Count (AGC/ANC/mm^3 - Do not report % granulocytes: report absolute count without decimal.)
Data type
float
Measurement units
- /mm^3
Alias
- NCI Thesaurus Property
- C20200
- NCI Thesaurus Property-2
- C12530
- NCI Thesaurus ValueDomain
- C25463
- NCI Thesaurus ObjectClass
- C25294
- UMLS CUI-1
- C0857490
Description
Platelets LLN
Data type
float
Alias
- NCI Thesaurus ObjectClass
- C25294
- UMLS CUI-1
- C0005821
- NCI Thesaurus Property
- C20200
- UMLS CUI-2
- C1518030
- NCI Thesaurus Property-2
- C12520
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus ValueDomain-2
- C25555
Description
Peripheral Platelet Count
Data type
float
Measurement units
- 1000/uL
Alias
- NCI Thesaurus Property
- C20200
- NCI Thesaurus Property-2
- C12520
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus ValueDomain
- C25712
- UMLS CUI-1
- C0005821
Description
LaboratoryProcedureBlastCellOutcomePercentageValue
Data type
float
Measurement units
- %
Alias
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus Property
- C20200
- NCI Thesaurus Property-2
- C12918
- NCI Thesaurus ValueDomain
- C25613
- NCI Thesaurus ValueDomain-2
- C25712
- UMLS CUI-1
- C0523113
Description
LaboratoryProcedureLeukocyteResultLowerLimitofNormalValue
Data type
float
Alias
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus Property
- C12529
- NCI Thesaurus Property-2
- C20200
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus ValueDomain-2
- C25555
- UMLS CUI-1
- C0023508
- UMLS CUI-2
- C1518030
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
Description
LaboratoryProcedureCreatinineResultUpperLimitNormalValue
Data type
float
Alias
- NCI Thesaurus Property
- C20200
- NCI Thesaurus Property-2
- C399
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus ValueDomain-2
- C25706
- UMLS CUI-1
- C0201976
- UMLS CUI-2
- C1519815
Description
Creatinine, Serum
Data type
float
Measurement units
- mg/dL
Alias
- NCI Thesaurus Property
- C20200
- UMLS CUI-1
- C0201976
- NCI Thesaurus Property-2
- C399
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus ValueDomain
- C25712
Description
Hemoglobin (Hgb), LLN
Data type
float
Measurement units
- g/dL
Alias
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus Property
- C16676
- NCI Thesaurus Property-2
- C20200
- NCI Thesaurus ValueDomain
- C25712
- NCI Thesaurus ValueDomain-2
- C38024
- NCI Thesaurus ValueDomain-3
- C25555
- UMLS CUI-1
- C0019046
- UMLS CUI-2
- C1518030
Description
Hemoglobin
Data type
float
Measurement units
- g/dL
Alias
- NCI Thesaurus Property
- C16676
- UMLS CUI-1
- C0019046
- NCI Thesaurus Property-2
- C20200
- NCI Thesaurus ObjectClass
- C25294
- NCI Thesaurus ValueDomain
- C25712
Description
CTC Adverse Event Attribution Code (Note: Use the standard CTC criteria, not the BMT-specific CTC criteria.)
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25664
- NCI Thesaurus ObjectClass
- C49704
- NCI Thesaurus Property
- C25358
- UMLS CUI-1
- C1706735
Description
AdverseDrugExperienceReportText
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25704
- NCI Thesaurus ObjectClass
- C25375
- NCI Metathesaurus ObjectClass
- C0085425
- NCI Thesaurus Property
- C25175
- UMLS CUI-1
- C2348483
Description
AdverseEventCommonTerminologyforAdverseEventsVersion4TermName
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- NCI Thesaurus Property
- C49704
- NCI Thesaurus Property-2
- C45559
- NCI Thesaurus ValueDomain
- C45255
- NCI Thesaurus ValueDomain-2
- C49704
- NCI Thesaurus ValueDomain-3
- C42614
- NCI Thesaurus ValueDomain-4
- C45559
- NCI Thesaurus ValueDomain-5
- C25714
- UMLS CUI-1
- C1516728
- UMLS CUI-2
- C2826934
Description
AdverseEventSeverityGrade CTC Adverse Event Grade (Note: Always provide CTC adverse event attribution code if an adverse event occurred. Also provide CTC AE v4 grade only if extenuating circumstances per the CTC AE v4 grading criteria would trigger a higher grade AE than the lab value would indicate.)
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C41331
- NCI Thesaurus Property
- C48309
- NCI Thesaurus Property-2
- C49705
- NCI Thesaurus Property-3
- C25676
- NCI Thesaurus ValueDomain
- C41331
- NCI Thesaurus ValueDomain-2
- C48309
- NCI Thesaurus ValueDomain-3
- C25676
- UMLS CUI-1
- C2985911
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INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files
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