ID

9200

Beschrijving

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

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

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

Engels

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 Formulieren  
Calgb Form
Beschrijving

Calgb Form

CALGB Study No.
Beschrijving

CALGBProtocolNumber

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

From
Beschrijving

IntervalReportFromDate

Datatype

date

To (MM DD YYYY)
Beschrijving

IntervalReportToDate

Datatype

date

Are data Amended?
Beschrijving

AmendedDataInd

Datatype

text

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

Patient Initials

Datatype

text

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

ParticipatingGroup

Datatype

text

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

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientID

Datatype

text

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

Cycle Number Chemotherapeutics

Datatype

float

Alias
UMLS CUI-1
C2045829
Bone Marrow
Beschrijving

Bone Marrow

Marrow Cellularity (0-100%)
Beschrijving

BoneMarrow,CellularityPercentage

Datatype

float

Bone Marrow Differential
Beschrijving

Bone Marrow Differential

Marrow Promyelocytes (%)
Beschrijving

BoneMarrow,Promyelocytes,CellPercentage

Datatype

float

Marrow Blasts (%)
Beschrijving

BoneMarrow,Blasts,CellPercentage

Datatype

float

Marrow Lymphocytes (%)
Beschrijving

BoneMarrow,Lymphocytes,CellPercentage

Datatype

float

Marrow Monocytes (%)
Beschrijving

MarrowMonocytes(%)

Datatype

text

Marrow Monoblasts (%)
Beschrijving

MarrowMonoblasts(%)

Datatype

text

Marrow Eosinophils (%)
Beschrijving

BoneMarrow,Eosinophils,CellPercentage

Datatype

float

Marrow Basophils (%)
Beschrijving

BoneMarrow,Basophils,CellPercentage

Datatype

float

Total Marrow Erythroid Cells (%)
Beschrijving

LaboratoryProcedureErythroidCellBoneMarrowResultPercentageValue

Datatype

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 (%)
Beschrijving

MarrowPlasmaCells(%)

Datatype

text

Megakaryocyte Status (MM DD YYYY)
Beschrijving

MegakaryocyteStatus

Datatype

text

% Marrow neutrophils
Beschrijving

%Marrowneutrophils

Datatype

text

% Marrow Metamyeocytes and Marrow Myelocytes
Beschrijving

%MarrowMetamyeocytesandMarrowMyelocytes

Datatype

text

Peripheral Blood Differential
Beschrijving

Peripheral Blood Differential

Date Specimen Collected
Beschrijving

Lab,Hematology,SampleCollectionDate

Datatype

date

Hemaglobin (gm/dl)
Beschrijving

Lab,Hematology,Hemoglobin

Datatype

float

Peripheral Platelet Count (1000/ml)
Beschrijving

Lab,Hematology,Platelets

Datatype

float

Peripheral WBC count
Beschrijving

Lab,Hematology,WBC

Datatype

float

Peripheral neutrophils (%) (bands, segs)
Beschrijving

Lab,Hematology,Neutrophils,CellPercentage

Datatype

float

Peripheral Metamyelocytes and Myelocytes (%)
Beschrijving

PeripheralMetamyelocytesandMyelocytes(%)

Datatype

text

Peripheral Promyelocytes (%)
Beschrijving

Lab,Hematology,Promyelocytes,CellPercentage

Datatype

float

Peripheral Blasts (%)
Beschrijving

Lab,Hematology,Blasts,CellPercentage

Datatype

float

Peripheral Lymphocytes (%)
Beschrijving

Lab,Hematology,Lymphocytes,CellPercentage

Datatype

float

Peripheral Monocytes (%)
Beschrijving

Lab,Hematology,Monocytes,CellPercentage

Datatype

float

Peripheral Monoblasts (%)
Beschrijving

PeripheralMonoblasts(%)

Datatype

text

Peripheral Eosinophils (%)
Beschrijving

Lab,Hematology,Eosinophils,CellPercentage

Datatype

float

Peripheral Basophils (%)
Beschrijving

Lab,Hematology,Basophils,CellPercentage

Datatype

float

Degree Of Dyspoiesis Present
Beschrijving

Degree Of Dyspoiesis Present

Myleopoiesis
Beschrijving

MyelopoiesisPresentRate

Datatype

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
Beschrijving

Erythropoiesis

Datatype

text

Megakaryopoiesis
Beschrijving

Megakaryopoiesis

Datatype

text

Completed by (Print or Type Name)
Beschrijving

CompletedBy

Datatype

text

Date Completed (MM DD YYYY)
Beschrijving

DateCompleted

Datatype

date

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

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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