ID

9200

Descrição

CALGB: 10201 PERIPHERAL BLOOD AND BONE MARROW REPORT 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=AD85FF2B-39F3-35D3-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AD85FF2B-39F3-35D3-E034-0003BA12F5E7

Palavras-chave

Versões (2)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT00085124 Lab - CALGB: 10201 PERIPHERAL BLOOD AND BONE MARROW REPORT FORM - 2031273v3.0

Inglês

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.

1 Formulários  
Calgb Form
Descrição

Calgb Form

CALGB Study No.
Descrição

CALGBProtocolNumber

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

From
Descrição

IntervalReportFromDate

Tipo de dados

date

To (MM DD YYYY)
Descrição

IntervalReportToDate

Tipo de dados

date

Are data Amended?
Descrição

AmendedDataInd

Tipo de dados

text

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

Patient Initials

Tipo de dados

text

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

ParticipatingGroup

Tipo de dados

text

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

PatientHospitalNumber

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Main Member Institution/Adjunct
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Participating Group Patient No.
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Current Course or Cycle No. (MM DD YYYY)
Descrição

Cycle Number Chemotherapeutics

Tipo de dados

float

Alias
UMLS CUI-1
C2045829
Bone Marrow
Descrição

Bone Marrow

Marrow Cellularity (0-100%)
Descrição

BoneMarrow,CellularityPercentage

Tipo de dados

float

Bone Marrow Differential
Descrição

Bone Marrow Differential

Marrow Promyelocytes (%)
Descrição

BoneMarrow,Promyelocytes,CellPercentage

Tipo de dados

float

Marrow Blasts (%)
Descrição

BoneMarrow,Blasts,CellPercentage

Tipo de dados

float

Marrow Lymphocytes (%)
Descrição

BoneMarrow,Lymphocytes,CellPercentage

Tipo de dados

float

Marrow Monocytes (%)
Descrição

MarrowMonocytes(%)

Tipo de dados

text

Marrow Monoblasts (%)
Descrição

MarrowMonoblasts(%)

Tipo de dados

text

Marrow Eosinophils (%)
Descrição

BoneMarrow,Eosinophils,CellPercentage

Tipo de dados

float

Marrow Basophils (%)
Descrição

BoneMarrow,Basophils,CellPercentage

Tipo de dados

float

Total Marrow Erythroid Cells (%)
Descrição

LaboratoryProcedureErythroidCellBoneMarrowResultPercentageValue

Tipo de dados

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C12431
UMLS 2011AA Property
C0005953
NCI Thesaurus Property-2
C20200
UMLS 2011AA Property-2
C1274040
NCI Thesaurus Property-3
C12508
UMLS 2011AA Property-3
C0007634
NCI Thesaurus Property-4
C13805
UMLS 2011AA Property-4
C1516960
NCI Thesaurus ValueDomain
C25613
UMLS 2011AA ValueDomain
C0439165
NCI Thesaurus ValueDomain-2
C25712
UMLS 2011AA ValueDomain-2
C1522609
Marrow Plasma Cells (%)
Descrição

MarrowPlasmaCells(%)

Tipo de dados

text

Megakaryocyte Status (MM DD YYYY)
Descrição

MegakaryocyteStatus

Tipo de dados

text

% Marrow neutrophils
Descrição

%Marrowneutrophils

Tipo de dados

text

% Marrow Metamyeocytes and Marrow Myelocytes
Descrição

%MarrowMetamyeocytesandMarrowMyelocytes

Tipo de dados

text

Peripheral Blood Differential
Descrição

Peripheral Blood Differential

Date Specimen Collected
Descrição

Lab,Hematology,SampleCollectionDate

Tipo de dados

date

Hemaglobin (gm/dl)
Descrição

Lab,Hematology,Hemoglobin

Tipo de dados

float

Peripheral Platelet Count (1000/ml)
Descrição

Lab,Hematology,Platelets

Tipo de dados

float

Peripheral WBC count
Descrição

Lab,Hematology,WBC

Tipo de dados

float

Peripheral neutrophils (%) (bands, segs)
Descrição

Lab,Hematology,Neutrophils,CellPercentage

Tipo de dados

float

Peripheral Metamyelocytes and Myelocytes (%)
Descrição

PeripheralMetamyelocytesandMyelocytes(%)

Tipo de dados

text

Peripheral Promyelocytes (%)
Descrição

Lab,Hematology,Promyelocytes,CellPercentage

Tipo de dados

float

Peripheral Blasts (%)
Descrição

Lab,Hematology,Blasts,CellPercentage

Tipo de dados

float

Peripheral Lymphocytes (%)
Descrição

Lab,Hematology,Lymphocytes,CellPercentage

Tipo de dados

float

Peripheral Monocytes (%)
Descrição

Lab,Hematology,Monocytes,CellPercentage

Tipo de dados

float

Peripheral Monoblasts (%)
Descrição

PeripheralMonoblasts(%)

Tipo de dados

text

Peripheral Eosinophils (%)
Descrição

Lab,Hematology,Eosinophils,CellPercentage

Tipo de dados

float

Peripheral Basophils (%)
Descrição

Lab,Hematology,Basophils,CellPercentage

Tipo de dados

float

Degree Of Dyspoiesis Present
Descrição

Degree Of Dyspoiesis Present

Myleopoiesis
Descrição

MyelopoiesisPresentRate

Tipo de dados

text

Alias
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C21143
UMLS 2011AA ObjectClass
C0525006
NCI Thesaurus ValueDomain
C25636
UMLS 2011AA ValueDomain
C1521828
Erythropoiesis
Descrição

Erythropoiesis

Tipo de dados

text

Megakaryopoiesis
Descrição

Megakaryopoiesis

Tipo de dados

text

Completed by (Print or Type Name)
Descrição

CompletedBy

Tipo de dados

text

Date Completed (MM DD YYYY)
Descrição

DateCompleted

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Calgb: 10201 Peripheral Blood And Bone Marrow Report Form
Descrição

Ccrr Module For Calgb: 10201 Peripheral Blood And Bone Marrow Report Form

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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.

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Calgb Form
CALGBProtocolNumber
Item
CALGB Study No.
text
CALGBPatientID
Item
CALGB Patient ID
text
IntervalReportFromDate
Item
From
date
IntervalReportToDate
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)
CL.1
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 or Cycle No. (MM DD YYYY)
float
C2045829 (UMLS CUI-1)
Item Group
Bone Marrow
BoneMarrow,CellularityPercentage
Item
Marrow Cellularity (0-100%)
float
Item Group
Bone Marrow Differential
BoneMarrow,Promyelocytes,CellPercentage
Item
Marrow Promyelocytes (%)
float
BoneMarrow,Blasts,CellPercentage
Item
Marrow Blasts (%)
float
BoneMarrow,Lymphocytes,CellPercentage
Item
Marrow Lymphocytes (%)
float
MarrowMonocytes(%)
Item
Marrow Monocytes (%)
text
MarrowMonoblasts(%)
Item
Marrow Monoblasts (%)
text
BoneMarrow,Eosinophils,CellPercentage
Item
Marrow Eosinophils (%)
float
BoneMarrow,Basophils,CellPercentage
Item
Marrow Basophils (%)
float
LaboratoryProcedureErythroidCellBoneMarrowResultPercentageValue
Item
Total Marrow Erythroid Cells (%)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C12431 (NCI Thesaurus Property)
C0005953 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C12508 (NCI Thesaurus Property-3)
C0007634 (UMLS 2011AA Property-3)
C13805 (NCI Thesaurus Property-4)
C1516960 (UMLS 2011AA Property-4)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
MarrowPlasmaCells(%)
Item
Marrow Plasma Cells (%)
text
Item
Megakaryocyte Status (MM DD YYYY)
text
CL.2
Code List
Megakaryocyte Status (MM DD YYYY)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Decreased (Decreased)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Increased (Increased)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
%Marrowneutrophils
Item
% Marrow neutrophils
text
%MarrowMetamyeocytesandMarrowMyelocytes
Item
% Marrow Metamyeocytes and Marrow Myelocytes
text
Item Group
Peripheral Blood Differential
Lab,Hematology,SampleCollectionDate
Item
Date Specimen Collected
date
Lab,Hematology,Hemoglobin
Item
Hemaglobin (gm/dl)
float
Lab,Hematology,Platelets
Item
Peripheral Platelet Count (1000/ml)
float
Lab,Hematology,WBC
Item
Peripheral WBC count
float
Lab,Hematology,Neutrophils,CellPercentage
Item
Peripheral neutrophils (%) (bands, segs)
float
PeripheralMetamyelocytesandMyelocytes(%)
Item
Peripheral Metamyelocytes and Myelocytes (%)
text
Lab,Hematology,Promyelocytes,CellPercentage
Item
Peripheral Promyelocytes (%)
float
Lab,Hematology,Blasts,CellPercentage
Item
Peripheral Blasts (%)
float
Lab,Hematology,Lymphocytes,CellPercentage
Item
Peripheral Lymphocytes (%)
float
Lab,Hematology,Monocytes,CellPercentage
Item
Peripheral Monocytes (%)
float
PeripheralMonoblasts(%)
Item
Peripheral Monoblasts (%)
text
Lab,Hematology,Eosinophils,CellPercentage
Item
Peripheral Eosinophils (%)
float
Lab,Hematology,Basophils,CellPercentage
Item
Peripheral Basophils (%)
float
Item Group
Degree Of Dyspoiesis Present
Item
Myleopoiesis
text
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C21143 (NCI Thesaurus ObjectClass)
C0525006 (UMLS 2011AA ObjectClass)
C25636 (NCI Thesaurus ValueDomain)
C1521828 (UMLS 2011AA ValueDomain)
CL.3
Code List
Myleopoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
Item
Erythropoiesis
text
CL.4
Code List
Erythropoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
Item
Megakaryopoiesis
text
CL.5
Code List
Megakaryopoiesis
CL Item
Marked (Marked)
C48662 (NCI Thesaurus)
C1706089 (UMLS 2011AA)
CL Item
Moderate (Moderate)
CL Item
Minimal (Minimal)
C0547039 (NCI Metathesaurus)
CL Item
Rare (Rare)
CL Item
Absent (Absent)
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 Peripheral Blood And Bone Marrow Report Form
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