ID

9199

Descrizione

CALGB: 10201 ADVERSE EVENT FORM Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AD846683-4685-2F05-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AD846683-4685-2F05-E034-0003BA12F5E7

Keywords

  1. 19/09/12 19/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy

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Leukemia NCT00085124 Toxicity - CALGB: 10201 ADVERSE EVENT FORM - 2070578v3.0

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

Calgb Form
Descrizione

Calgb Form

CALGB Study No.
Descrizione

CALGBProtocolNumber

Tipo di dati

text

CALGB Patient ID
Descrizione

CALGBPatientID

Tipo di dati

text

From
Descrizione

CTCAdverseEventReportBeginDate

Tipo di dati

date

To (MM DD YYYY)
Descrizione

CTCAdverseEventReportEndDate

Tipo di dati

date

Are data Amended?
Descrizione

AmendedDataInd

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient's Initials (Last, First, Middle)
Descrizione

Patient Initials

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Participating Group
Descrizione

ParticipatingGroup

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descrizione

PatientHospitalNumber

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Main Member Institution/Adjunct
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Participating Group Patient No.
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Current Course/Cycle No.
Descrizione

Cycle Number Chemotherapeutics

Tipo di dati

float

Alias
UMLS CUI-1
C2045829
Treatment Phase
Descrizione

TreatmentPhase

Tipo di dati

text

Was an AER/ADR filed with Central Office based on an event reported below?
Descrizione

WasanAER/ADRfiledwithCentralOfficebasedonaneventreportedbelow?

Tipo di dati

boolean

Expected Adverse Events
Descrizione

Expected Adverse Events

MedDRA Code
Descrizione

MedDRACode

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Metathesaurus ObjectClass
CL104089
MedDRA Code
Descrizione

MedDRACode

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Metathesaurus ObjectClass
CL104089
CTC Adverse Event Term
Descrizione

CTCAdverseEventTerm

Tipo di dati

text

CTC Adverse Event Term
Descrizione

CTCAdverseEventTerm

Tipo di dati

text

Were there any other events (Hematologic grade 4-5 only or Non-Hematologic grade 3-5 only) noted during this time period?
Descrizione

Werethereanyotherevents(Hematologicgrade4-5onlyorNon-Hematologicgrade3-5only)notedduringthistimeperiod?

Tipo di dati

boolean

CTC Grade
Descrizione

CTCAdverseEventGrade

Tipo di dati

float

CTC Grade
Descrizione

CTCAdverseEventGrade

Tipo di dati

float

Attribution
Descrizione

CTCAdverseEventAttributionCode

Tipo di dati

text

Attribution
Descrizione

CTCAdverseEventAttributionCode

Tipo di dati

text

Completed by (Print or Type Name)
Descrizione

CompletedBy

Tipo di dati

text

Date Completed (MM DD YYYY)
Descrizione

DateCompleted

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Calgb: 10201 Adverse Event Form
Descrizione

Ccrr Module For Calgb: 10201 Adverse Event Form

Similar models

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Calgb Form
CALGBProtocolNumber
Item
CALGB Study No.
text
CALGBPatientID
Item
CALGB Patient ID
text
CTCAdverseEventReportBeginDate
Item
From
date
CTCAdverseEventReportEndDate
Item
To (MM DD YYYY)
date
Item
Are data Amended?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Code List
Are data Amended?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient Initials
Item
Patient's Initials (Last, First, Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Affiliate
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
Cycle Number Chemotherapeutics
Item
Current Course/Cycle No.
float
C2045829 (UMLS CUI-1)
Item
Treatment Phase
text
Code List
Treatment Phase
CL Item
Current Phase Of Leukemia Treatment For Patient Is Induction (Induction)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Consolidation (Consolidation)
CL Item
Current Phase Of Leukemia Treatment For Patient Is Specified Other Phase (Other, specify)
WasanAER/ADRfiledwithCentralOfficebasedonaneventreportedbelow?
Item
Was an AER/ADR filed with Central Office based on an event reported below?
boolean
Item Group
Expected Adverse Events
MedDRACode
Item
MedDRA Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
MedDRACode
Item
MedDRA Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
Werethereanyotherevents(Hematologicgrade4-5onlyorNon-Hematologicgrade3-5only)notedduringthistimeperiod?
Item
Were there any other events (Hematologic grade 4-5 only or Non-Hematologic grade 3-5 only) noted during this time period?
boolean
CTCAdverseEventGrade
Item
CTC Grade
float
CTCAdverseEventGrade
Item
CTC Grade
float
Item
Attribution
text
Code List
Attribution
CL Item
Unrelated (unrelated to treatment)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely to be related to treatment)
CL Item
Possible (possibly related to treatment)
C0332149 (NCI Metathesaurus)
CL Item
Probable (probably related to treatment)
C0332148 (NCI Metathesaurus)
CL Item
Definite (definitely related to treatment)
Item
Attribution
text
Code List
Attribution
CL Item
Unrelated (unrelated to treatment)
C25328 (NCI Thesaurus)
C0445356 (UMLS 2011AA)
CL Item
Unlikely (unlikely to be related to treatment)
CL Item
Possible (possibly related to treatment)
C0332149 (NCI Metathesaurus)
CL Item
Probable (probably related to treatment)
C0332148 (NCI Metathesaurus)
CL Item
Definite (definitely related to treatment)
CompletedBy
Item
Completed by (Print or Type Name)
text
DateCompleted
Item
Date Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Calgb: 10201 Adverse Event Form

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