No Instruction available.

  1. StudyEvent: ADVL0212: Eligibility Worksheet (Leukemia)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Protocol ID COG
Item
COG Study Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516477 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Protocol ID COG
Item
COG Study Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516477 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
PatientCOGIdentifierNumber
Item
COG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)
Patient Initials
Item
Patient's Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Eligibility Assessment
TreatmentRequiredBeginDateInd-2
Item
Is the planned start of treatment within five working days of fulfilling all eligibility criteria?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
PatientRequiredAgeInd-2
Item
Is patient less than 22 years of age at the time of study entry?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25652 (NCI Thesaurus Property)
C1514873 (UMLS 2011AA Property)
C25150 (NCI Thesaurus Property-2)
C0001779 (UMLS 2011AA Property-2)
DiseaseHistologicDiagnosisInd
Item
Does patient have histologic verification of the malignancy at original diagnosis
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
DiseaseTreatmentRefractoryInd-2
Item
Is patient's disease considered refractory to conventional therapy, or is there no existing effective conventional therapy
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
Item
If patient has a CNS tumor, were neurologic deficits relatively stable for a minimum of two weeks prior to study entry?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C37940 (NCI Thesaurus Property)
C0011155 (UMLS 2011AA Property)
Code List
If patient has a CNS tumor, were neurologic deficits relatively stable for a minimum of two weeks prior to study entry?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
N/a, Patient Does Not Have A Cns Tumor (N/A, patient does not have a CNS tumor)
Item
Karnofsky Performance Score
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C28013 (NCI Thesaurus ObjectClass)
C0206065 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Code List
Karnofsky Performance Score
CL Item
100 (Normal, no complaints, no evidence of disease.)
CL Item
90 (Able to carry on normal activity, minor signs or symptoms of disease.)
CL Item
80 (Normal activity with effort, some signs or symptoms of disease.)
CL Item
70 (Cares for self. Unable to carry on normal activity or to do active work.)
CL Item
60 (Requires occasional assistance, but is able to care for most of own needs.)
CL Item
50 (Requires considerable assistance and frequent medical care.)
CL Item
40 (Disabled, requires special care and assistance.)
CL Item
30 (Severely disabled, hospitalization is indicated although death is not imminent.)
CL Item
20 (Hospitalization necessary, very sick, active supportive treatment necessary,)
CL Item
10 (Moribund, fatal processes progressing rapidly.)
CL Item
0 (Dead.)
C0919414 (NCI Metathesaurus)
Item
Lansky Play Score
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25361 (NCI Thesaurus ObjectClass)
C0597198 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Code List
Lansky Play Score
CL Item
100 (Fully active, normal.)
CL Item
90 (Minor restrictions in physically strenuous activity.)
CL Item
80 (Active, but tires more quickly.)
CL Item
70 (Both greater restriction of and less time spent in play activity.)
CL Item
60 (Up and around, but minimal active play; keeps busy with quieter activities.)
CL Item
50 (Gets dressed but lies around much of the day, no active play, able to participate in all quiet play and activities.)
CL Item
40 (Mostly in bed; participates in quiet activities.)
CL Item
30 (In bed; needs assistance even for quiet play.)
CL Item
20 (Often sleeping; play entirely limited to very passive activities.)
CL Item
10 (No play; does not get out of bed.)
CL Item
0 (Unresponsive.)
C0919414 (NCI Metathesaurus)
PatientLifeExpectancyEligibilityDeterminationInd-2
Item
Does patient have a life expectancy of greater than or equal to 8 weeks?
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C37987 (NCI Thesaurus Property)
C0376558 (UMLS 2011AA Property)
C25171 (NCI Thesaurus Property-2)
C0013893 (UMLS 2011AA Property-2)
C25359 (NCI Thesaurus Property-3)
C0679138 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
PatientRecoveryEligibilityInd-2
Item
Has patient fully recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiotherapy prior to entering this study?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25746 (NCI Thesaurus Property)
C2004454 (UMLS 2011AA Property)
PriorGrowthFactorReceivedInd-2
Item
Did patient receive growth factors within 1 week of entry onto this study?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C20424 (NCI Thesaurus ObjectClass-2)
C0018284 (UMLS 2011AA ObjectClass-2)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
Item
If patient has a CNS tumor and is receiving dexamethasone, is patient on a stable dose for at least two weeks prior to study entry?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
Code List
If patient has a CNS tumor and is receiving dexamethasone, is patient on a stable dose for at least two weeks prior to study entry?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
N/a, Patient Does Not Have A Cns Tumor (N/A, patient does not have a CNS tumor)
CL Item
N/a, Patient Has A Cns Tumor, But Is Not Receiving Dexamethasone (N/A, patient has CNS tumor, but is not receiving dexamethasone)
AnticonvulsantMedicationReceivedInd-2
Item
Is patient receiving enzyme-inducing anticonvulsant drugs?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
PatientBoneMarrowFunctionRequiredInd-2
Item
Does patient have adequate bone marrow function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
PatientRenalFunctionRequiredInd-2
Item
Does patient have adequate renal function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
PatientLiverFunctionRequiredInd-2
Item
Does patient have adequate liver function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
PatientCardiacFunctionRequiredInd-2
Item
Does patient have adequate cardiac function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
PatientPulmonaryFunctionRequiredInd-2
Item
Does patient have adequate pulmonary function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
PatientCNSFunctionRequiredInd-2
Item
Does patient have adequate central nervous system function?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus Property)
C0542341 (UMLS 2011AA Property)
Item
If female and post-menarchal, was a pregnancy test obtained?
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
Code List
If female and post-menarchal, was a pregnancy test obtained?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
N/a, Patient Is Female, But Not Post-menarchal (N/A, patient is female, but not post-menarchal)
CL Item
N/a, Patient Is Male (N/A, patient is male)
Item
is the patient pregnant?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
Code List
is the patient pregnant?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
CL Item
No, And Not Nursing (no, and not nursing)
CL Item
No, But Nursing (no, but nursing)
Item
has he or she agreed to use an effective contraceptive method?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C37932 (NCI Thesaurus ObjectClass)
C0700589 (UMLS 2011AA ObjectClass)
C25369 (NCI Thesaurus Property)
C0680240 (UMLS 2011AA Property)
Code List
has he or she agreed to use an effective contraceptive method?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
N/a, Patient Is Not Of Reproductive Potential (N/A, patient is not of reproductive potential)
PatientInfectionInd-2
Item
Does patient have an uncontrolled infection?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C26726 (NCI Thesaurus Property)
C0009450 (UMLS 2011AA Property)
Agent
Item
agent name
text
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C1521826 (UMLS CUI-1)
AgentReceivedInd-2
Item
Has patient previously received Depsipeptide?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
PatientRequiredCharacteristicsCOGInd-2
Item
Does patient have the following: Symptoms of congestive heart failure, Uncontrolled cardiac rhythm disturbance, or QTC that is greater than or equal to 480 msec
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25447 (NCI Thesaurus Property)
C1521970 (UMLS 2011AA Property)
InformedConsentFormSignedDate
Item
Date informed consent signed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C16468 (NCI Thesaurus ObjectClass)
C0009797 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Treatment Assignment
TreatmentAssignmentText
Item
Dose level/duration assignment
text
C25704 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25426 (NCI Thesaurus Property)
C1527021 (UMLS CUI-1)
C1516050 (UMLS CUI-2)
Item Group
Ccrr Module For Advl0212: Eligibility Worksheet (leukemia)

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial