ID

372

Description

E1900 Material Submission Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E0B4-B257-2F80-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A727E0B4-B257-2F80-E034-0003BA0B1A09

Keywords

Versions (4)
  1. 5/25/12 5/25/12 -
  2. 2/4/15 2/4/15 - Martin Dugas
  3. 7/9/15 7/9/15 - Martin Dugas
  4. 9/20/21 9/20/21 -
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May 25, 2012

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Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT00049517 Pathology - E1900 Material Submission Form - 2053688v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Registration Step
Description

RegistrationStep

Data type

text

Patient?s Name
Description

Patient'sName

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

ECOG Patient ID
Description

ECOGPatientID

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Unnamed2
Description

Unnamed2

Completed By Submitting Institutions
Description

Completed By Submitting Institutions

Date material(s) sent to central laboratory
Description

SpecimenCentralLaboratorySubmissionDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C37984
UMLS 2011AA Property
C0022877
NCI Metathesaurus Property
C0205099
NCI Thesaurus Property
C25694
UMLS 2011AA Property
C1515022
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Shipped to
Description

SpecimenLaboratoryReceivedLocationName

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C37984
UMLS 2011AA Property
C0022877
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
Sample type
Description

Sampletype

Data type

text

Date Materials collected
Description

SpecimenCollectionDate

Data type

date

Tissue/material type
Description

SpecimenSubmittedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Type of collection/stain/process
Description

Typeofcollection/stain/process

Data type

text

Timing of material collection
Description

SpecimenCollectionPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25453
UMLS 2011AA Property
C1516698
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
number of specimens submitted
Description

numberofspecimenssubmitted

Data type

text

Diagnosis
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Absolute blast count
Description

Lab,Hematology,BlastCount

Data type

double

Institution contact name
Description

ContactPersonatInstitution

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
Principal Investigator name
Description

RegisteredInvestigator

Data type

text

Institution contact phone number
Description

InstitutionContactTelephoneNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
Institution contact fax number
Description

InstitutionContactFaxNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C25210
UMLS 2011AA Property
C0085205
Completed By Central Lab
Description

Completed By Central Lab

Date materials received at central lab
Description

SpecimenReceivedDate

Data type

date

Sample type
Description

Sampletype

Data type

text

Condition of material(s)
Description

SpecimenCondition

Data type

text

Aliquots of sample made
Description

Aliquotsofsamplemade

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Central Laboratory contact name
Description

CentralLaboratoryContactPersonName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C37984
UMLS 2011AA ObjectClass
C0022877
NCI Metathesaurus ObjectClass
C0205099
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
contact phone number
Description

CentralLaboratoryContactTelephoneNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Contact fax number
Description

CentralLaboratoryContactFaxNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25210
UMLS 2011AA Property
C0085205
Comments
Description

Comments

Data type

text

Investigator signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For E1900 Material Submission Form
Description

Ccrr Module For E1900 Material Submission Form

Peripheral and Marrow Blast Percentage (%)
Description

PeripheralandMarrowBlastPercentage(%)

Data type

text

Sample No.
Description

SampleNo.

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
Item Group
Completed By Submitting Institutions
SpecimenCentralLaboratorySubmissionDate
Item
Date material(s) sent to central laboratory
date
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus Property)
C0022877 (UMLS 2011AA Property)
C0205099 (NCI Metathesaurus Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Shipped to
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C37984 (NCI Thesaurus Property)
C0022877 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
CL.1
Code List
Shipped to
CL Item
Leukemia Immunophenotyping Reference Library (Leukemia Immunophenotyping Reference Library)
CL Item
Ecog Cytogenetics Laboratory (ECOG Cytogenetics Laboratory)
CL Item
Other Central Laboratory (Other Central Laboratory)
Item
Sample type
text
CL.7
Code List
Sample type
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
SpecimenCollectionDate
Item
Date Materials collected
date
Item
Tissue/material type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.3
Code List
Tissue/material type
CL Item
Peripheral Blood (peripheral blood)
C0229664 (NCI Metathesaurus)
CL Item
Bone Marrow Aspirate (bone marrow aspirate)
CL042344 (NCI Metathesaurus)
CL Item
Bone Marrow Biopsy (bone marrow biopsy)
C15193 (NCI Thesaurus)
C0005954 (UMLS 2011AA)
CL Item
Karyotype (karyotype)
C25215 (NCI Thesaurus)
C1261273 (UMLS 2011AA)
CL Item
Peripheral Blood Stem Cell Harvest (peripheral blood stem cell harvest)
C0457411 (NCI Metathesaurus)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Type of collection/stain/process
text
CL.4
Code List
Type of collection/stain/process
CL Item
Green Top (heparinized) (green top (heparinized))
CL Item
Red Top (red top)
CL Item
Slide, Unstained, Charged (slide, unstained, charged)
CL Item
Slide/air Dried Smear (slide/air dried smear)
CL Item
Karyotype (karyotype)
C25215 (NCI Thesaurus)
C1261273 (UMLS 2011AA)
CL Item
Stem Cell Harvest (stem cell harvest)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
Timing of material collection
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
CL.5
Code List
Timing of material collection
CL Item
Baseline/pretreatment (baseline/pretreatment)
CL Item
Pre-transplant Remission Prior To Consolidation (pre-transplant remission prior to consolidation)
CL Item
Pre-transplant , Post-consolidation Chemotherapy (pre-transplant , post-consolidation chemotherapy)
CL Item
1 Mo. Post-transplant (1 mo. Post-transplant)
CL Item
6 Mos. Post-transplant (6 mos. Post-transplant)
CL Item
12 Mos. Post-transplant (12 mos. Post-transplant)
CL Item
Stem Cell Harvest (stem cell harvest)
CL Item
Relapse (relapse)
C18265 (NCI Thesaurus)
CL Item
Other (other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
numberofspecimenssubmitted
Item
number of specimens submitted
text
Item
Diagnosis
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
CL.6
Code List
Diagnosis
CL Item
Disease Classified As Aml, Not Otherwise Specified (nos) (acute myeloid leukemia)
CL Item
Disease Classified As All, Not Otherwise Specified (nos); (acute lymphocytic leukemia)
CL Item
Disease Classified As Chronic Myelogenous Leukemia, (cml), Blast Crisis (CML - blast cells)
CL Item
Disease Classified As Chronic Lymphocytic Leukemia (cll) (chronic lymphocytic leukemia)
CL Item
Disease Classified As Chronic Myelogenous Leukemia (cml), Chronic Phase (CML-chronic phase)
CL Item
Disease Classified As Myelodysplastic Syndrome (mds) Nos (MDS-myelodysplastic syndrome)
CL Item
Disease Classified As Specified Other Leukemia (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown (Unknown)
Lab,Hematology,BlastCount
Item
Absolute blast count
double
ContactPersonatInstitution
Item
Institution contact name
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
RegisteredInvestigator
Item
Principal Investigator name
text
InstitutionContactTelephoneNumber
Item
Institution contact phone number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
InstitutionContactFaxNumber
Item
Institution contact fax number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
Item Group
Completed By Central Lab
SpecimenReceivedDate
Item
Date materials received at central lab
date
Item
Sample type
text
CL.7
Code List
Sample type
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
Item
Condition of material(s)
text
CL.8
Code List
Condition of material(s)
CL Item
Damaged Or Unusable (not usable as received)
CL Item
Useable (usable as received)
Item
Aliquots of sample made
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.9
Code List
Aliquots of sample made
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CentralLaboratoryContactPersonName
Item
Central Laboratory contact name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C0205099 (NCI Metathesaurus ObjectClass)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
CentralLaboratoryContactTelephoneNumber
Item
contact phone number
text
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C64207 (NCI Thesaurus ObjectClass)
C1880016 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)
CentralLaboratoryContactFaxNumber
Item
Contact fax number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C64207 (NCI Thesaurus ObjectClass)
C1880016 (UMLS 2011AA ObjectClass)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For E1900 Material Submission Form
PeripheralandMarrowBlastPercentage(%)
Item
Peripheral and Marrow Blast Percentage (%)
text
SampleNo.
Item
Sample No.
text
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