Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB C-215 Secondary Form
C1320722 (UMLS CUI-1)
CALGB Form
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGB Study No
Item
CALGB Study No
text
C3274381 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
CALGB Patient ID
Item
CALGB Patient ID
text
C2348585 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
data amended
Item
Are data amended
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI [1,1])
C1691222 (UMLS CUI [1,2])
Patient Name
Item
Patient's Name
text
C1299487 (UMLS CUI [1])
Patient Hospital Number
Item
Patient Hospital Number
text
C0421459 (UMLS CUI [1])
Main Member Institution
Item
Main Member Institution/Adjunct
text
C1301943 (UMLS CUI [1])
Participating Group
Item
Participating Group
text
C2347449 (UMLS CUI [1])
Participating Group Protocol No.
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Participating Group Patient Number
Item
Participating Group Patient No.
text
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Second Primary Tumor Diagnosis Date
Item
Date of diagnosis of secondary AML/MDS
date
C3262 (NCI Thesaurus ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C25666 (NCI Thesaurus ObjectClass-3)
C15220 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0751623 (UMLS CUI [1,1])
C2316983 (UMLS CUI [1,2])
Report sent
Item
Has the NCI/CTEP secondary AML/MDS report form been sent to the CALGB central office?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0684224 (UMLS CUI [1])
missing form reason
Item
Explain why the form was not sent
text
C0814891 (UMLS CUI [1])
Submission date
Item
Date the form was sent
date
C1515022 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI-1)
Completed by
Item
Completed by
text
C1550483 (UMLS CUI [1])
Date Form Completed
Item
Date Form Completed
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI-1)

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