ID

9207

Beschreibung

Supplemental Laboratory Report Form Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7039E38-F4C1-1898-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7039E38-F4C1-1898-E034-0003BA0B1A09

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00049543 Lab - Supplemental Laboratory Report Form - 2036656v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: Supplemental Laboratory Report Form
    1. No Instruction available.
Patient Information
Beschreibung

Patient Information

Patient Study ID, Coordinating Group
Beschreibung

PatientStudyID,CoordinatingGroup

Datentyp

text

Patient Initials (first - middle - last)
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Beschreibung

PatientMedicalRecordNumber

Datentyp

text

Institution Name
Beschreibung

InstitutionName

Datentyp

text

Registered Investigator (NCI Investigator #)
Beschreibung

RegisteredInvestigator

Datentyp

text

Month Of Report
Beschreibung

Month Of Report

Month of report (circle one)
Beschreibung

VisitReportMonthCount

Datentyp

text

Alias
NCI Thesaurus Property
C29846
UMLS 2011AA Property
C0439231
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Other
Beschreibung

VisitReportMonthSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C29846
UMLS 2011AA Property
C0439231
NCI Thesaurus ObjectClass
C25375
UMLS 2011AA ObjectClass
C0684224
NCI Thesaurus ObjectClass-2
C25716
UMLS 2011AA ObjectClass-2
C0545082
Biochemistry
Beschreibung

Biochemistry

Specimen Collection Date (Biochemistry, yyyy mmm dd)
Beschreibung

SpecimenCollectionDate

Datentyp

date

Lab Unit of Measure (circle unit used)
Beschreibung

Lab,UnitsofMeasure

Datentyp

text

Bilirubin (uL or 10 9/L)
Beschreibung

Lab,Hepatic,Bilirubin

Datentyp

float

Bilirubin ULN
Beschreibung

HepaticBilirubinLabUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C305
UMLS 2011AA Property-2
C0005437
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
SGOT (AST) (U/L; * If alkaline phosphatase is greater than ULN but < 2.5 X ULN, ultrasound or CT scan of abdomen and bone scan MUST be done prior to randomization)
Beschreibung

Lab,Hepatic,SGOT

Datentyp

float

SGOT (AST) ULN
Beschreibung

SGOTLabUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
SGPT (ALT) (U/L; * If alkaline phosphatase is greater than ULN but < 2.5 X ULN, ultrasound or CT scan of abdomen and bone scan MUST be done prior to randomization)
Beschreibung

Lab,Hepatic,SGPT

Datentyp

float

SGPT (ALT) ULN
Beschreibung

SGPTLabUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Alkaline Phosphatase (U/L; ** If AST SGOT or ALT SGPT is greater than ULN but < 2.5 X ULN, ultrasound, CT or MRI or abdomen MUST be done prior to randomization.)
Beschreibung

Lab,Hepatic,AlkalinePhosphatase

Datentyp

float

Alkaline Phosphatase ULN
Beschreibung

Alkaline Phosphatase ULN

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0151420
NCI Thesaurus Property
C20200
NCI Thesaurus Property-2
C16276
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
Lactate Dehydrogenase (LDH) (U/L)
Beschreibung

Lab,Chemistry,LactateDehydrogenase

Datentyp

float

Lactate Dehydrogenase ULN
Beschreibung

Lab,Chemistry,LactateDehydrogenase,ULN

Datentyp

float

Creatinine (mg/dl or umol/L)
Beschreibung

Lab,Renal,Creatinine

Datentyp

float

Creatinine ULN
Beschreibung

Creatinine, serum ULN

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS CUI-1
C0201976
NCI Thesaurus Property
C20200
UMLS CUI-2
C1519815
NCI Thesaurus Property-2
C399
NCI Thesaurus ValueDomain
C25712
NCI Thesaurus ValueDomain-2
C25706
BUN (mg/dl or umol/L)
Beschreibung

Lab,Renal,BUN

Datentyp

float

BUN ULN
Beschreibung

LaboratoryProcedureBloodUreaNitrogenResultUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C61019
UMLS 2011AA Property-2
C0005845
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Potassium (K) (mEq/L)
Beschreibung

Lab,Electrolytes,Potassium

Datentyp

float

Potassium LLN
Beschreibung

LaboratoryProcedurePotassiumElectrolytesOutcomeLowerLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C464
UMLS 2011AA Property-2
C0013832
NCI Thesaurus Property-3
C765
UMLS 2011AA Property-3
C0032821
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25555
UMLS 2011AA ValueDomain-2
C1518030
Potassium ULN
Beschreibung

LaboratoryProcedurePotassiumElectrolytesOutcomeUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C464
UMLS 2011AA Property-2
C0013832
NCI Thesaurus Property-3
C765
UMLS 2011AA Property-3
C0032821
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Sodium (Na) (mmol/L)
Beschreibung

Lab,Electrolytes,Sodium

Datentyp

float

Sodium LLN
Beschreibung

LaboratoryProcedureSodiumElectrolytesOutcomeLowerLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C830
UMLS 2011AA Property-2
C0037473
NCI Thesaurus Property-3
C464
UMLS 2011AA Property-3
C0013832
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25555
UMLS 2011AA ValueDomain-2
C1518030
Sodium ULN
Beschreibung

LaboratoryProcedureSodiumElectrolytesOutcomeUpperLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C830
UMLS 2011AA Property-2
C0037473
NCI Thesaurus Property-3
C464
UMLS 2011AA Property-3
C0013832
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Chloride (Cl) (mEq/L)
Beschreibung

Lab,Electrolytes,Chloride

Datentyp

float

Chloride LLN
Beschreibung

LaboratoryProcedureChlorideIonElectrolytesOutcomeLowerLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C464
UMLS 2011AA Property-2
C0013832
NCI Thesaurus Property-3
C1741
UMLS 2011AA Property-3
C0596019
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25555
UMLS 2011AA ValueDomain-2
C1518030
Chloride ULN
Beschreibung

LaboratoryProcedureChlorideIonElectrolytesOutcomeUpperLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C464
UMLS 2011AA Property-2
C0013832
NCI Thesaurus Property-3
C1741
UMLS 2011AA Property-3
C0596019
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Calcium (Ca) (mg/dL or umol/L)
Beschreibung

Lab,Electrolytes,Calcium

Datentyp

float

Calcium LLN
Beschreibung

LaboratoryProcedureCalciumElectrolytesOutcomeLowerLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C331
UMLS 2011AA Property
C0006675
NCI Thesaurus Property-2
C20200
UMLS 2011AA Property-2
C1274040
NCI Thesaurus Property-3
C464
UMLS 2011AA Property-3
C0013832
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25555
UMLS 2011AA ValueDomain-2
C1518030
Calcium ULN
Beschreibung

LaboratoryProcedureCalciumElectrolytesOutcomeUpperLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C331
UMLS 2011AA Property
C0006675
NCI Thesaurus Property-2
C20200
UMLS 2011AA Property-2
C1274040
NCI Thesaurus Property-3
C464
UMLS 2011AA Property-3
C0013832
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Albumin (g/dl or g/L)
Beschreibung

Chemistry,BloodAlbumin

Datentyp

float

Albumin LLN
Beschreibung

LaboratoryProcedureAlbuminResultLowerLimitofNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C214
UMLS 2011AA Property-2
C0001924
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25555
UMLS 2011AA ValueDomain-2
C1518030
Albumin ULN
Beschreibung

LaboratoryProcedureAlbuminResultUpperLimitNormalValue

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property-2
C214
UMLS 2011AA Property-2
C0001924
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain-2
C25706
UMLS 2011AA ValueDomain-2
C1519815
Ncic Ctg Use Only
Beschreibung

Ncic Ctg Use Only

Logged
Beschreibung

LoggedEntryInitials

Datentyp

text

Unnamed (Logged Date)
Beschreibung

LoggedEntryDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
RA
Beschreibung

RegulatoryAffairsReviewInitials

Datentyp

text

Unnamed (RA Date)
Beschreibung

RegulatoryAffairsReviewDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Study Coord
Beschreibung

CoordinatorReviewInitials

Datentyp

text

Unnamed (Coord Date)
Beschreibung

CoordinatorReviewDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Phy
Beschreibung

PhysicianReviewInitials

Datentyp

text

Data Ent'd
Beschreibung

DataEntryInitials

Datentyp

text

Verified
Beschreibung

DataVerificationInitials

Datentyp

text

Header
Beschreibung

Header

Patient Study ID, Coordinating Group
Beschreibung

PatientStudyID,CoordinatingGroup

Datentyp

text

Patient Initials (first - middle - last)
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Hematology
Beschreibung

Hematology

Date Hematology (Blood) Sample Obtained (yyyy mmm dd)
Beschreibung

Lab,Hematology,SampleCollectionDate

Datentyp

date

Lab Unit of Measure (circle unit used)
Beschreibung

Lab,UnitsofMeasure

Datentyp

text

Hemoglobin (g/dl or g/L)
Beschreibung

Lab,Hematology,Hemoglobin

Datentyp

float

Peripheral Platelet Count (1000/uL or x 10 9/L)
Beschreibung

Lab,Hematology,Platelets

Datentyp

float

Peripheral WBC Count (1000/uL or x 10 9/L)
Beschreibung

Lab,Hematology,WBC

Datentyp

float

Peripheral Neutrophils (%)
Beschreibung

Lab,Hematology,Neutrophils,CellPercentage

Datentyp

float

Comments
Beschreibung

Comments

COMMENTS
Beschreibung

Comments

Datentyp

text

Investigator Signature
Beschreibung

Investigator Signature

Investigator Signature
Beschreibung

InvestigatorSignature

Datentyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Beschreibung

PersonCompletingForm,LastName

Datentyp

text

Person Completing Form, First Name
Beschreibung

PersonCompletingForm,FirstName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Beschreibung

FormCompletionDate,Original

Datentyp

date

Ccrr Module For Supplemental Laboratory Report Form
Beschreibung

Ccrr Module For Supplemental Laboratory Report Form

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1 Formulare
  1. StudyEvent: Supplemental Laboratory Report Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Month Of Report
Item
Month of report (circle one)
text
C29846 (NCI Thesaurus Property)
C0439231 (UMLS 2011AA Property)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
CL.1
Code List
Month of report (circle one)
CL Item
1 (1)
CL Item
3 (3)
CL Item
6 (6)
CL Item
9 (9)
CL Item
12 (12)
CL Item
15 (15)
CL Item
18 (18)
CL Item
21 (21)
CL Item
24 (24)
CL Item
27 Months (27)
CL Item
30 (30)
CL Item
36 (36)
CL Item
42 (42)
CL Item
48 (48)
CL Item
54 (54)
CL Item
60 (60)
CL Item
Other Month (Other)
VisitReportMonthSpecify
Item
Other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C29846 (NCI Thesaurus Property)
C0439231 (UMLS 2011AA Property)
C25375 (NCI Thesaurus ObjectClass)
C0684224 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0545082 (UMLS 2011AA ObjectClass-2)
Item Group
Biochemistry
SpecimenCollectionDate
Item
Specimen Collection Date (Biochemistry, yyyy mmm dd)
date
Item
Lab Unit of Measure (circle unit used)
text
CL.3
Code List
Lab Unit of Measure (circle unit used)
CL Item
G/dl (g/dl)
CL Item
G/l (g/L)
CL Item
1000/ul (1000/uL)
CL Item
X10^9/l (10 9/L)
CL Item
% (%)
Lab,Hepatic,Bilirubin
Item
Bilirubin (uL or 10 9/L)
float
HepaticBilirubinLabUpperLimitNormalValue
Item
Bilirubin ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C305 (NCI Thesaurus Property-2)
C0005437 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Hepatic,SGOT
Item
SGOT (AST) (U/L; * If alkaline phosphatase is greater than ULN but < 2.5 X ULN, ultrasound or CT scan of abdomen and bone scan MUST be done prior to randomization)
float
SGOTLabUpperLimitNormalValue
Item
SGOT (AST) ULN
float
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Hepatic,SGPT
Item
SGPT (ALT) (U/L; * If alkaline phosphatase is greater than ULN but < 2.5 X ULN, ultrasound or CT scan of abdomen and bone scan MUST be done prior to randomization)
float
SGPTLabUpperLimitNormalValue
Item
SGPT (ALT) ULN
float
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Hepatic,AlkalinePhosphatase
Item
Alkaline Phosphatase (U/L; ** If AST SGOT or ALT SGPT is greater than ULN but < 2.5 X ULN, ultrasound, CT or MRI or abdomen MUST be done prior to randomization.)
float
Alkaline Phosphatase ULN
Item
Alkaline Phosphatase ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0151420 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C16276 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
Lab,Chemistry,LactateDehydrogenase
Item
Lactate Dehydrogenase (LDH) (U/L)
float
Lab,Chemistry,LactateDehydrogenase,ULN
Item
Lactate Dehydrogenase ULN
float
Lab,Renal,Creatinine
Item
Creatinine (mg/dl or umol/L)
float
Creatinine, serum ULN
Item
Creatinine ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0201976 (UMLS CUI-1)
C20200 (NCI Thesaurus Property)
C1519815 (UMLS CUI-2)
C399 (NCI Thesaurus Property-2)
C25712 (NCI Thesaurus ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
Lab,Renal,BUN
Item
BUN (mg/dl or umol/L)
float
LaboratoryProcedureBloodUreaNitrogenResultUpperLimitNormalValue
Item
BUN ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C61019 (NCI Thesaurus Property-2)
C0005845 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Electrolytes,Potassium
Item
Potassium (K) (mEq/L)
float
LaboratoryProcedurePotassiumElectrolytesOutcomeLowerLimitNormalValue
Item
Potassium LLN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C464 (NCI Thesaurus Property-2)
C0013832 (UMLS 2011AA Property-2)
C765 (NCI Thesaurus Property-3)
C0032821 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedurePotassiumElectrolytesOutcomeUpperLimitNormalValue
Item
Potassium ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C464 (NCI Thesaurus Property-2)
C0013832 (UMLS 2011AA Property-2)
C765 (NCI Thesaurus Property-3)
C0032821 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Electrolytes,Sodium
Item
Sodium (Na) (mmol/L)
float
LaboratoryProcedureSodiumElectrolytesOutcomeLowerLimitofNormalValue
Item
Sodium LLN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C830 (NCI Thesaurus Property-2)
C0037473 (UMLS 2011AA Property-2)
C464 (NCI Thesaurus Property-3)
C0013832 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureSodiumElectrolytesOutcomeUpperLimitofNormalValue
Item
Sodium ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C830 (NCI Thesaurus Property-2)
C0037473 (UMLS 2011AA Property-2)
C464 (NCI Thesaurus Property-3)
C0013832 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Electrolytes,Chloride
Item
Chloride (Cl) (mEq/L)
float
LaboratoryProcedureChlorideIonElectrolytesOutcomeLowerLimitofNormalValue
Item
Chloride LLN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C464 (NCI Thesaurus Property-2)
C0013832 (UMLS 2011AA Property-2)
C1741 (NCI Thesaurus Property-3)
C0596019 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureChlorideIonElectrolytesOutcomeUpperLimitofNormalValue
Item
Chloride ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C464 (NCI Thesaurus Property-2)
C0013832 (UMLS 2011AA Property-2)
C1741 (NCI Thesaurus Property-3)
C0596019 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Lab,Electrolytes,Calcium
Item
Calcium (Ca) (mg/dL or umol/L)
float
LaboratoryProcedureCalciumElectrolytesOutcomeLowerLimitofNormalValue
Item
Calcium LLN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C331 (NCI Thesaurus Property)
C0006675 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C464 (NCI Thesaurus Property-3)
C0013832 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureCalciumElectrolytesOutcomeUpperLimitofNormalValue
Item
Calcium ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C331 (NCI Thesaurus Property)
C0006675 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C464 (NCI Thesaurus Property-3)
C0013832 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Chemistry,BloodAlbumin
Item
Albumin (g/dl or g/L)
float
LaboratoryProcedureAlbuminResultLowerLimitofNormalValue
Item
Albumin LLN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C214 (NCI Thesaurus Property-2)
C0001924 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureAlbuminResultUpperLimitNormalValue
Item
Albumin ULN
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C214 (NCI Thesaurus Property-2)
C0001924 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Unnamed (Logged Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
RegulatoryAffairsReviewInitials
Item
RA
text
RegulatoryAffairsReviewDate
Item
Unnamed (RA Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Unnamed (Coord Date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Header
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Hematology
Lab,Hematology,SampleCollectionDate
Item
Date Hematology (Blood) Sample Obtained (yyyy mmm dd)
date
Item
Lab Unit of Measure (circle unit used)
text
CL.3
Code List
Lab Unit of Measure (circle unit used)
CL Item
G/dl (g/dl)
CL Item
G/l (g/L)
CL Item
1000/ul (1000/uL)
CL Item
X10^9/l (10 9/L)
CL Item
% (%)
Lab,Hematology,Hemoglobin
Item
Hemoglobin (g/dl or g/L)
float
Lab,Hematology,Platelets
Item
Peripheral Platelet Count (1000/uL or x 10 9/L)
float
Lab,Hematology,WBC
Item
Peripheral WBC Count (1000/uL or x 10 9/L)
float
Lab,Hematology,Neutrophils,CellPercentage
Item
Peripheral Neutrophils (%)
float
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Supplemental Laboratory Report Form
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