ID

372

Descrição

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

Palavras-chave

Versões (4)
  1. 25/05/2012 25/05/2012 -
  2. 04/02/2015 04/02/2015 - Martin Dugas
  3. 09/07/2015 09/07/2015 - Martin Dugas
  4. 20/09/2021 20/09/2021 -
Transferido a

25 de maio de 2012

DOI

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

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient?s Name
Descrição

Patient'sName

Tipo de dados

text

ECOG Protocol No.
Descrição

ECOGProtocolNo.

Tipo de dados

text

ECOG Protocol No.
Descrição

ECOGProtocolNo.

Tipo de dados

text

ECOG Patient ID
Descrição

ECOGPatientID

Tipo de dados

text

ECOG Patient ID
Descrição

ECOGPatientID

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Participating Group Patient ID
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Institution/Affiliate
Descrição

MainMemberInstitution/Affiliate

Tipo de dados

text

Unnamed2
Descrição

Unnamed2

Completed By Submitting Institutions
Descrição

Completed By Submitting Institutions

Date material(s) sent to central laboratory
Descrição

SpecimenCentralLaboratorySubmissionDate

Tipo de dados

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
Descrição

SpecimenLaboratoryReceivedLocationName

Tipo de dados

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
Descrição

Sampletype

Tipo de dados

text

Date Materials collected
Descrição

SpecimenCollectionDate

Tipo de dados

date

Tissue/material type
Descrição

SpecimenSubmittedType

Tipo de dados

text

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

Typeofcollection/stain/process

Tipo de dados

text

Timing of material collection
Descrição

SpecimenCollectionPeriodType

Tipo de dados

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
Descrição

numberofspecimenssubmitted

Tipo de dados

text

Diagnosis
Descrição

Leukemia/MDSClassification

Tipo de dados

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
Descrição

Lab,Hematology,BlastCount

Tipo de dados

double

Institution contact name
Descrição

ContactPersonatInstitution

Tipo de dados

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
Descrição

RegisteredInvestigator

Tipo de dados

text

Institution contact phone number
Descrição

InstitutionContactTelephoneNumber

Tipo de dados

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
Descrição

InstitutionContactFaxNumber

Tipo de dados

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
Descrição

Completed By Central Lab

Date materials received at central lab
Descrição

SpecimenReceivedDate

Tipo de dados

date

Sample type
Descrição

Sampletype

Tipo de dados

text

Condition of material(s)
Descrição

SpecimenCondition

Tipo de dados

text

Aliquots of sample made
Descrição

Aliquotsofsamplemade

Tipo de dados

text

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

CentralLaboratoryContactPersonName

Tipo de dados

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
Descrição

CentralLaboratoryContactTelephoneNumber

Tipo de dados

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
Descrição

CentralLaboratoryContactFaxNumber

Tipo de dados

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
Descrição

Comments

Tipo de dados

text

Investigator signature
Descrição

InvestigatorSignature

Tipo de dados

text

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

InvestigatorSignatureDate

Tipo de dados

date

Ccrr Module For E1900 Material Submission Form
Descrição

Ccrr Module For E1900 Material Submission Form

Peripheral and Marrow Blast Percentage (%)
Descrição

PeripheralandMarrowBlastPercentage(%)

Tipo de dados

text

Sample No.
Descrição

SampleNo.

Tipo de dados

text

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: E1900 Material Submission Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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