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
Cytogenetics Referral Form
C0010802 (UMLS CUI-1)
CALGB Form
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGB Study Number
Item
CALGB Treatment Study #
text
C3274381 (UMLS CUI [1,1])
C1516238 (UMLS CUI [1,2])
CALGB Companion Study Number
Item
CALGB Companion Study #
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])
Amended Data
Item
Amended Data?
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])
Hospital Number
Item
Patient Hospital Number
text
C0806432 (UMLS CUI [1])
Main Member Institution/Adjunct
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 No.
Item
Participating Group Patient No.
text
C2348585 (UMLS CUI [1,1])
C2347449 (UMLS CUI [1,2])
Item
Sex
text
C25372 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C17357 (NCI Thesaurus Property)
C0079399 (UMLS CUI [1])
Code List
Sex
CL Item
Male (male)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
CL Item
Female (female)
C46110 (NCI Thesaurus)
C0086287 (UMLS 2011AA)
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Code List
Diagnosis
CL Item
ALL (ALL)
C0023449 (UMLS CUI-1)
(Comment:en)
CL Item
AML (AML)
C0023467 (UMLS CUI-1)
(Comment:en)
CL Item
MDS (MDS)
C3463824 (UMLS CUI-1)
(Comment:en)
CL Item
CML (CML)
C0023473 (UMLS CUI-1)
(Comment:en)
CL Item
Other, specify (Other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)
Other, specify
Item
Other, specify
text
C3845569 (UMLS CUI [1])
Date sample received
Item
Date sample obtained
date
C0460065 (UMLS CUI [1])
other, specify
Item
other, specify
text
C3845569 (UMLS CUI [1])
other, specify
Item
other, specify
text
C25179 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C3845569 (UMLS CUI [1])
WBC
Item
WBC
float
C0023508 (UMLS CUI [1])
Percentage Blasts, blood
Item
% Blasts
float
C0587348 (UMLS CUI [1,1])
C0005767 (UMLS CUI [1,2])
Percentage Blasts, bone marrow
Item
% Blasts BM
float
C0587348 (UMLS CUI [1,1])
C0005953 (UMLS CUI [1,2])
Completed By
Item
Completed By
text
C1550483 (UMLS CUI [1])
Date Completed
Item
Date Completed
date
C25164 (NCI Thesaurus ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI [1])
Telephone Number
Item
Telephone Number
text
C25704 (NCI Thesaurus ValueDomain)
C1515258 (UMLS CUI [1])
Item
Sample type
text
C2347029 (UMLS CUI [1])
Code List
Sample type
CL Item
sample obtained (sample obtained)
C1277697 (UMLS CUI-1)
(Comment:en)
CL Item
bone marrow aspirate (bone marrow aspirate)
C1271729 (UMLS CUI-1)
(Comment:en)
CL Item
blood (blood)
C0005767 (UMLS CUI-1)
(Comment:en)
CL Item
other, specify (other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)
Item
If bone marrow not submitted, give reason
text
C0566251 (UMLS CUI [1,1])
C3640292 (UMLS CUI [1,2])
Code List
If bone marrow not submitted, give reason
CL Item
inaspirable (inaspirable)
C0398523 (UMLS CUI-1)
C1272705 (UMLS CUI-2)
(Comment:en)
CL Item
other, specify (other, specify)
C3845569 (UMLS CUI-1)
(Comment:en)

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