ID

373

Description

E1900 Cover Page for Adverse Event 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=B19AAD35-91C7-25DB-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B19AAD35-91C7-25DB-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 5/25/12 5/25/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

May 25, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT00049517 Toxicity - E1900 Cover Page for Adverse Event Form - 2075062v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: E1900 Cover Page for Adverse Event Form
    1. No Instruction available.
Unnamed1
Description

Unnamed1

DCI Name
Description

CollectedDataFormName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
Patient Initials
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
ECOG Protocol Number
Description

ECOGProtocolNumber

Data type

text

ECOG Protocol Number
Description

ECOGProtocolNumber

Data type

text

ECOG Protocol Number
Description

ECOGProtocolNumber

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

On Treatment
Description

On Treatment

On Treatment Time Period
Description

OnTreatmentTimePeriod

Data type

text

Off Treatment
Description

Off Treatment

Off Treatment Time Period
Description

OffTreatmentTimePeriod

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25601
UMLS 2011AA Property
C1518544
NCI Thesaurus Property
C25207
UMLS 2011AA Property
C0040223
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Ccrr Module For E1900 Cover Page For Adverse Event Form
Description

Ccrr Module For E1900 Cover Page For Adverse Event Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E1900 Cover Page for Adverse Event Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
PatientInitialsName
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ECOGProtocolNumber
Item
ECOG Protocol Number
text
ECOGProtocolNumber
Item
ECOG Protocol Number
text
ECOGProtocolNumber
Item
ECOG Protocol Number
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
On Treatment
Item
On Treatment Time Period
text
CL.1
Code List
On Treatment Time Period
CL Item
Induction (Induction)
CL042203 (NCI Metathesaurus)
CL Item
Induction, Additional Forms (Induction, additional Forms)
CL Item
Consolidation (Consolidation)
CL Item
Post-transplant (Post-Transplant)
Item Group
Off Treatment
Item
Off Treatment Time Period
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C25207 (NCI Thesaurus Property)
C0040223 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.2
Code List
Off Treatment Time Period
CL Item
3 Months (3 months)
CL Item
6 Months (6 months)
CL Item
9 Months (9 months)
CL Item
12 Months (12 months)
CL Item
15 Months (15 months)
CL Item
18 Months (18 months)
CL Item
24 Months (24 months)
CL Item
30 Months (30 months)
CL Item
36 Months (36 months)
CL Item
42 Months (42 months)
CL Item
48 Months (48 months)
CL Item
54 Months (54 months)
CL Item
60 Months (60 months)
CL Item
2 Years (2 years)
CL Item
3 Years (3 years)
CL Item
4 Years (4 years)
CL Item
5 Years (5 years)
CL Item
6 Years (6 years)
CL Item
7 Years (7 years)
CL Item
8 Years (8 years)
CL Item
9 Years (9 years)
CL Item
10 Years (10 years)
Item Group
Ccrr Module For E1900 Cover Page For Adverse Event Form
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