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8977

Beschrijving

E2906 Registration Worksheet (step 1) Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=85FA2555-1EC1-F884-E040-BB89AD432656

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=85FA2555-1EC1-F884-E040-BB89AD432656

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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9 januari 2015

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Creative Commons BY-NC 3.0 Legacy
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    Leukemia NCT01041703 Eligibility - E2906 Registration Worksheet (step 1) - 3082845v1.0

    Engels

    No Instruction available.

    1 Formulieren  
    1. StudyEvent: E2906 Registration Worksheet (step 1)
      1. No Instruction available.
    Eligibility
    Beschrijving

    Eligibility

    Has the eligibility checklist been completed
    Beschrijving

    EligibilityDeterminationChecklistCompleteEligibilityInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ObjectClass
    C25171
    UMLS 2011AA ObjectClass
    C0013893
    NCI Thesaurus Property-2
    C49073
    UMLS 2011AA Property-2
    C1707357
    In the opinion of the investigator, is the patient eligible?
    Beschrijving

    Eligibility for trial

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1302261
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25171
    Has written informed consent been obtained
    Beschrijving

    Consent signed

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0742766
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25678
    NCI Thesaurus Property-2
    C25460
    Date Informed Consent Signed
    Beschrijving

    InformedConsentFormSignedDate

    Datatype

    date

    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
    Has HIPAA authorization been obtained
    Beschrijving

    HealthInsurancePortabilityandAccountabilityActAuthorizationIndicator

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C62504
    UMLS 2011AA ObjectClass
    C0600593
    NCI Thesaurus Property
    C41192
    UMLS 2011AA Property
    C1524004
    HIPAA Authorization Date
    Beschrijving

    PatientSignedDischargeMedicalRecordDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25679
    NCI Metathesaurus Property
    C0012621
    NCI Thesaurus Property-2
    C45258
    UMLS 2011AA Property
    C0025102
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Cytogenetic results
    Beschrijving

    PatientCytogeneticsOutcomeEligibilityDeterminationStatus

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C16487
    UMLS 2011AA Property
    C0010802
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus Property-3
    C25171
    UMLS 2011AA Property-3
    C0013893
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Therapy-related AML
    Beschrijving

    Therapy-RelatedAcuteMyeloidLeukemiaDiagnosisInd-3

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ObjectClass
    C8252
    UMLS 2011AA ObjectClass
    C1336735
    Antecedent hematologic disorders
    Beschrijving

    PriorHematologicDiseaseorDisorderDiagnosisInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C62780
    UMLS 2011AA ObjectClass
    C0205488
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus ObjectClass-3
    C2991
    UMLS 2011AA ObjectClass-3
    C0012634
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Patient has consented to take part in the Quality of Life Study
    Beschrijving

    PatientQualityofLifeConsentInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C17047
    UMLS 2011AA Property
    C0518214
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property-2
    C25460
    UMLS 2011AA Property-2
    C1511481
    If the patient has been registered to E3903, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    Beschrijving

    PersonAncillaryStudyRegistrationText

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25646
    UMLS 2011AA Property
    C1514821
    NCI Thesaurus Property-2
    C16041
    UMLS 2011AA Property-2
    C1515980
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    Beschrijving

    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C15207
    NCI Thesaurus Property-3
    C25294
    UMLS 2011AA Property-2
    C0022885
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    I agree to provide additional blood for research.
    Beschrijving

    PersonBloodTissueDonorConsentIndicator

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25168
    UMLS 2011AA Property
    C0040288
    NCI Thesaurus Property-2
    C12434
    UMLS 2011AA Property-2
    C0229664
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    May your coded samples and related coded information be kept for use in research to learn about, prevent, find or treat cancer? This may also include research on inherited traits (genes passed on in families).
    Beschrijving

    PersonSpecimenMalignantNeoplasmResearchConsentInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C9305
    UMLS 2011AA Property
    C0006826
    NCI Thesaurus Property-3
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-4
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    May your coded samples and related coded information be kept for use in research to learn about, prevent, find or treat other health problems (for example: diabetes, Alzheimer's disease, or heart disease)? This may also include research on inherited traits (genes passed on in families).
    Beschrijving

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C12801
    UMLS 2011AA Property
    C0040300
    NCI Thesaurus Property-2
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Someone from this institution may contact me in the future to ask me to take part in more research.
    Beschrijving

    PatientAdditionalResearchConsentInd-2

    Datatype

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25406
    UMLS 2011AA Property
    C1524062
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Terug naar het begin van de pagina

    Similar models

    No Instruction available.

    1 Formulieren
    1. StudyEvent: E2906 Registration Worksheet (step 1)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Eligibility
    EligibilityDeterminationChecklistCompleteEligibilityInd-2
    Item
    Has the eligibility checklist been completed
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25171 (NCI Thesaurus ObjectClass)
    C0013893 (UMLS 2011AA ObjectClass)
    C49073 (NCI Thesaurus Property-2)
    C1707357 (UMLS 2011AA Property-2)
    Eligibility for trial
    Item
    In the opinion of the investigator, is the patient eligible?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1302261 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25171 (NCI Thesaurus Property)
    Consent signed
    Item
    Has written informed consent been obtained
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C0742766 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25678 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    date
    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)
    Item
    Has HIPAA authorization been obtained
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C62504 (NCI Thesaurus ObjectClass)
    C0600593 (UMLS 2011AA ObjectClass)
    C41192 (NCI Thesaurus Property)
    C1524004 (UMLS 2011AA Property)
    CL.4
    Code List
    Has HIPAA authorization been obtained
    CL Item
    No: C49487 (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes: C49488 (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Exempt - Non-usa Participant (Exempt - non-USA participant)
    PatientSignedDischargeMedicalRecordDate
    Item
    HIPAA Authorization Date
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    C0012621 (NCI Metathesaurus Property)
    C45258 (NCI Thesaurus Property-2)
    C0025102 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Cytogenetic results
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C16487 (NCI Thesaurus Property)
    C0010802 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25171 (NCI Thesaurus Property-3)
    C0013893 (UMLS 2011AA Property-3)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Cytogenetic results
    CL Item
    Unfavorable (Unfavorable)
    CL Item
    Other (Other)
    Therapy-RelatedAcuteMyeloidLeukemiaDiagnosisInd-3
    Item
    Therapy-related AML
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C8252 (NCI Thesaurus ObjectClass)
    C1336735 (UMLS 2011AA ObjectClass)
    PriorHematologicDiseaseorDisorderDiagnosisInd-2
    Item
    Antecedent hematologic disorders
    boolean
    C62780 (NCI Thesaurus ObjectClass)
    C0205488 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C2991 (NCI Thesaurus ObjectClass-3)
    C0012634 (UMLS 2011AA ObjectClass-3)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientQualityofLifeConsentInd-2
    Item
    Patient has consented to take part in the Quality of Life Study
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C17047 (NCI Thesaurus Property)
    C0518214 (UMLS 2011AA Property)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25460 (NCI Thesaurus Property-2)
    C1511481 (UMLS 2011AA Property-2)
    PersonAncillaryStudyRegistrationText
    Item
    If the patient has been registered to E3903, please enter the ECOG patient ID assigned. Others enter 'N/A'.
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25646 (NCI Thesaurus Property)
    C1514821 (UMLS 2011AA Property)
    C16041 (NCI Thesaurus Property-2)
    C1515980 (UMLS 2011AA Property-2)
    PersonLaboratoryProcedureCurrentClinicalTrialConsentInd-2
    Item
    I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C15207 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus Property-3)
    C0022885 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PersonBloodTissueDonorConsentIndicator
    Item
    I agree to provide additional blood for research.
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25168 (NCI Thesaurus Property)
    C0040288 (UMLS 2011AA Property)
    C12434 (NCI Thesaurus Property-2)
    C0229664 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    PersonSpecimenMalignantNeoplasmResearchConsentInd-2
    Item
    May your coded samples and related coded information be kept for use in research to learn about, prevent, find or treat cancer? This may also include research on inherited traits (genes passed on in families).
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C9305 (NCI Thesaurus Property-2)
    C0006826 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-3)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-4)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2
    Item
    May your coded samples and related coded information be kept for use in research to learn about, prevent, find or treat other health problems (for example: diabetes, Alzheimer's disease, or heart disease)? This may also include research on inherited traits (genes passed on in families).
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C12801 (NCI Thesaurus Property)
    C0040300 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-2)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientAdditionalResearchConsentInd-2
    Item
    Someone from this institution may contact me in the future to ask me to take part in more research.
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C25406 (NCI Thesaurus Property-2)
    C1524062 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
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