Information:
Error:
ID
9762
Description
S0100 CNS LEUKEMIA EVALUATION FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB474AE-AD1A-426C-E034-0003BA12F5E7
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Versions (1)
- 1/22/15 1/22/15 - Martin Dugas
Uploaded on
January 22, 2015
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License
Creative Commons BY-NC 3.0 Legacy
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Leukemia Follow-Up - S0100 CNS LEUKEMIA EVALUATION FORM
Instructions: Please complete and submit this form within 14 days after the lumbar puncture. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
Similar models
Instructions: Please complete and submit this form within 14 days after the lumbar puncture. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
SWOGPatientID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
C1519429 (UMLS CUI-2)
SWOGStudyNo.
Item
SWOG Study No.
text
C3274381 (UMLS CUI-1)
C1519429 (UMLS CUI-2)
C1519429 (UMLS CUI-2)
RegistrationStep
Item
Registration Step
text
C1514821 (UMLS CUI-1)
PatientInitials
Item
Patient Initials (L, F, M)
text
C2986440 (UMLS CUI-1)
Institution
Item
Institution/Affiliate
text
C0565990 (UMLS CUI-1)
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI-1)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI-1)
Lumbar Puncture Date
Item
Date of Lumbar Puncture
date
C0037943 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
C0011008 (UMLS CUI-2)
CL Item
Present (Present)
CL Item
Absent (Absent)
CL Item
Indeterminate (Indeterminate)