ID

9681

Description

E1900 Long-Term Follow-up Form Combination Chemotherapy With or Without Monoclonal Antibody Therapy Followed by Stem Cell Transplant in Treating Patients With Acute Myeloid Leukemia NCT00049517 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294868-3C8F-2FCA-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A7294868-3C8F-2FCA-E034-0003BA0B1A09

Keywords

Versions (2)
  1. 5/25/12 5/25/12 -
  2. 1/10/15 1/10/15 - Martin Dugas
Uploaded on

January 10, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Long-Term Follow-up Form Leukemia (NCT00049517)

English

No Instruction available.

1 forms  
  1. StudyEvent: E1900 Long-Term Follow-up Form
    1. No Instruction available.
Header
Description

Header

Alias
UMLS CUI-1
C1320722
ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C1512162
ECOG Patient ID
Description

ECOGPatientID

Data type

text

Alias
UMLS CUI-1
C2348585
UMLS CUI-2
C1512162
Registration Step
Description

Registration Step

Data type

text

Alias
UMLS CUI-1
C1514821
Patient's Name
Description

Patient Name

Data type

text

Alias
UMLS CUI-1
C1299487
Participating Group Protocol No.
Description

Protocol ID Participating Group

Data type

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C2347449
Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Alias
UMLS CUI-1
C2348585
UMLS CUI-2
C2347449
Institution/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Alias
UMLS CUI-1
C1301943
Are data amended?
Description

AmendedDataInd (If yes, please circle amended items in red)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI-1
C1511726
UMLS CUI-2
C1691222
Reporting Period Start Date
Description

IntervalReportFromDate

Data type

date

Measurement units
  • M D Y
Alias
UMLS CUI-1
C2361257
M D Y
Reporting Period End Date
Description

IntervalReportToDate

Data type

date

Measurement units
  • M D Y
Alias
UMLS CUI-1
C2361259
M D Y
Comments
Description

Comments

Data type

text

Alias
UMLS CUI-1
C0947611
Investigator Signature
Description

Investigator Signature

Data type

text

Alias
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
UMLS CUI-1
C2346576
Investigator Signature Date
Description

InvestigatorSignatureDate

Data type

date

Alias
UMLS CUI-1
C2346576
UMLS CUI-2
C0011008
Vital Status
Description

Vital Status

Alias
UMLS CUI-1
C1148433
Patient's Vital Status
Description

Patient Vital Status

Data type

text

Alias
UMLS CUI-1
C1148433
Date of Last Contact or Death
Description

DeathDate/LastContactDate

Data type

date

Measurement units
  • M D Y
Alias
UMLS CUI-1
C0805839
UMLS CUI-2
C1148348
M D Y
Primary Cause of Death
Description

DeathReason

Data type

text

Alias
UMLS CUI-1
C0007465
Describe cause of death
Description

DeathReason,Specify

Data type

text

Alias
UMLS CUI-1
C0007465
UMLS CUI-2
C1521902
Disease Follow-up Status
Description

Disease Follow-up Status

Alias
UMLS CUI-1
C0589120
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)?
Description

CancerFollow-upStatusInd

Data type

boolean

Alias
UMLS CUI-1
C1522577
UMLS CUI-2
C0006826
Date of last clinical cancer assessment (If yes)
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus Property
C25365
UMLS CUI-1
C3694716
UMLS CUI-2
C0006826
Notice Of Relapse
Description

Notice Of Relapse

Alias
UMLS CUI-1
C0277556
Has the patient developed a first relapse that has not been previously reported?
Description

Tumor Progression

Data type

boolean

Alias
UMLS CUI-1
C0178874
Date of relapse
Description

Date of Relapse

Data type

date

Alias
UMLS CUI-1
C0035020
UMLS CUI-2
C0011008
Did a physician make a formal diagnosis of relapse? (If no or unknown, specify basis of PD in Comments)
Description

Relapse certain

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus Property
C25254
NCI Thesaurus Property-2
C15220
UMLS CUI-1
C0035020
UMLS CUI-2
C0205423
Notice Of New Primary
Description

Notice Of New Primary

Alias
UMLS CUI-1
C0751623
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Description

New Primary Cancer

Data type

boolean

Alias
UMLS CUI-1
C0751623
Site(s) of new primary
Description

New Primary Cancer Site

Data type

text

Alias
UMLS CUI-1
C0751623
UMLS CUI-2
C1515974
Toxicity
Description

Toxicity

Alias
UMLS CUI-1
C0040539
Has the patient experienced any severe (Grade >= 3) long term toxicity that has not been previously reported?
Description

LateAdverseEventInd

Data type

boolean

Alias
UMLS CUI-1
C0040539
UMLS CUI-2
C0443252
Non-protocol Therapy
Description

Non-protocol Therapy

Alias
UMLS CUI-1
C1518384
UMLS CUI-2
C0087111
Has the patient received any non-protocol cancer therapy prior to first relapse (not previously reported)?
Description

Hasthepatientreceivedanynon-protocolcancertherapypriortofirstprogression(notpreviouslyreported)?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1518384
UMLS CUI-2
C0087111
Transfusions
Description

Transfusions

Alias
UMLS CUI-1
C1879316
Number of platlet transfusions (this reporting period)
Description

PlateletTransfusionReceivedUnitCount

Data type

integer

Alias
NCI Thesaurus ValueDomain
C44278
NCI Thesaurus Property
C25639
NCI Thesaurus ValueDomain-2
C25463
NCI Thesaurus ObjectClass
C15366
UMLS CUI-1
C0086818
Date of most recent platelet transfusion
Description

Platelet Transfusion, recent date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25639
NCI Thesaurus ObjectClass
C15366
NCI Thesaurus ValueDomain-2
C25577
UMLS CUI-1
C0086818
UMLS CUI-2
C0332185
Number of RBC transfusions (this reporting period)
Description

PackedRedBloodCellTransfusionReceivedUnitCount

Data type

integer

Alias
NCI Thesaurus ValueDomain
C44278
NCI Thesaurus Property
C25639
NCI Thesaurus ValueDomain-2
C25463
NCI Thesaurus ObjectClass
C15409
UMLS CUI-1
C0086252
Date of most recent RBC transfusion
Description

PackedRedBloodCellTransfusionReceivedMostRecentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25639
NCI Thesaurus ObjectClass
C15409
NCI Thesaurus ValueDomain-2
C25577
UMLS CUI-1
C0086252
UMLS CUI-2
C0332185
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: E1900 Long-Term Follow-up Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
Protocol ID ECOG
Item
ECOG Protocol No.
text
C3274381 (UMLS CUI-1)
C1512162 (UMLS CUI-2)
ECOG Patient ID
Item
ECOG Patient ID
text
C2348585 (UMLS CUI-1)
C1512162 (UMLS CUI-2)
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI-1)
Patient Name
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
Protocol ID Participating Group
Item
Participating Group Protocol No.
text
C3274381 (UMLS CUI-1)
C2347449 (UMLS CUI-2)
Patient ID Participating Group
Item
Participating Group Patient ID
text
C2348585 (UMLS CUI-1)
C2347449 (UMLS CUI-2)
Institution
Item
Institution/Affiliate
text
C1301943 (UMLS CUI-1)
Data amended
Item
Are data amended?
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI-1)
C1691222 (UMLS CUI-2)
Reporting Period Start Date
Item
Reporting Period Start Date
date
C2361257 (UMLS CUI-1)
Reporting Period End Date
Item
Reporting Period End Date
date
C2361259 (UMLS CUI-1)
Comments
Item
Comments
text
C0947611 (UMLS CUI-1)
Investigator Signature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
Investigator Signature Date
Item
Investigator Signature Date
date
C2346576 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Item Group
Vital Status
C1148433 (UMLS CUI-1)
Item
Patient's Vital Status
text
C1148433 (UMLS CUI-1)
CL.2
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Date of Last Contact or Death
Item
Date of Last Contact or Death
date
C0805839 (UMLS CUI-1)
C1148348 (UMLS CUI-2)
Item
Primary Cause of Death
text
C0007465 (UMLS CUI-1)
CL.3
Code List
Primary Cause of Death
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Other Cause, Specify (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Death Reason, Specify
Item
Describe cause of death
text
C0007465 (UMLS CUI-1)
C1521902 (UMLS CUI-2)
Item Group
Disease Follow-up Status
C0589120 (UMLS CUI-1)
Follow-Up Cancer
Item
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)?
boolean
C1522577 (UMLS CUI-1)
C0006826 (UMLS CUI-2)
Follow-up Date Cancer
Item
Date of last clinical cancer assessment (If yes)
date
C2991 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C3694716 (UMLS CUI-1)
C0006826 (UMLS CUI-2)
Item Group
Notice Of Relapse
C0277556 (UMLS CUI-1)
Tumor Progression
Item
Has the patient developed a first relapse that has not been previously reported?
boolean
C0178874 (UMLS CUI-1)
Date of Relapse
Item
Date of relapse
date
C0035020 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Relapse certain
Item
Did a physician make a formal diagnosis of relapse? (If no or unknown, specify basis of PD in Comments)
boolean
C38148 (NCI Thesaurus ValueDomain)
C25741 (NCI Thesaurus ObjectClass)
C25254 (NCI Thesaurus Property)
C15220 (NCI Thesaurus Property-2)
C0035020 (UMLS CUI-1)
C0205423 (UMLS CUI-2)
Item Group
Notice Of New Primary
C0751623 (UMLS CUI-1)
New Primary Cancer
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
boolean
C0751623 (UMLS CUI-1)
New Primary Cancer Site
Item
Site(s) of new primary
text
C0751623 (UMLS CUI-1)
C1515974 (UMLS CUI-2)
Item Group
Toxicity
C0040539 (UMLS CUI-1)
Toxicity, long-term
Item
Has the patient experienced any severe (Grade >= 3) long term toxicity that has not been previously reported?
boolean
C0040539 (UMLS CUI-1)
C0443252 (UMLS CUI-2)
Item Group
Non-protocol Therapy
C1518384 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Non-protocol Therapy
Item
Has the patient received any non-protocol cancer therapy prior to first relapse (not previously reported)?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1518384 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Item Group
Transfusions
C1879316 (UMLS CUI-1)
Platelet Transfusion
Item
Number of platlet transfusions (this reporting period)
integer
C44278 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C25463 (NCI Thesaurus ValueDomain-2)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS CUI-1)
Platelet Transfusion, recent date
Item
Date of most recent platelet transfusion
date
C25164 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C15366 (NCI Thesaurus ObjectClass)
C25577 (NCI Thesaurus ValueDomain-2)
C0086818 (UMLS CUI-1)
C0332185 (UMLS CUI-2)
Red Blood Cell Transfusion
Item
Number of RBC transfusions (this reporting period)
integer
C44278 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C25463 (NCI Thesaurus ValueDomain-2)
C15409 (NCI Thesaurus ObjectClass)
C0086252 (UMLS CUI-1)
Red Blood Cell Transfusion, recent date
Item
Date of most recent RBC transfusion
date
C25164 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C15409 (NCI Thesaurus ObjectClass)
C25577 (NCI Thesaurus ValueDomain-2)
C0086252 (UMLS CUI-1)
C0332185 (UMLS CUI-2)
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