ID

10635

Description

CALGB: TRACKING FORM (TISSUE BLOCKS) NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D4607-D11F-30F7-E034-080020C9C0E0

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D4607-D11F-30F7-E034-080020C9C0E0

Mots-clés

Versions (4)
  1. 26/08/2012 26/08/2012 -
  2. 22/05/2015 22/05/2015 -
  3. 03/06/2015 03/06/2015 -
  4. 03/06/2015 03/06/2015 -
Téléchargé le

3 juin 2015

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy
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CALGB: TRACKING FORM (TISSUE BLOCKS) NCT00024102

Anglais

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 Formulaires  
CALGB clinical trial administrative data
Description

CALGB clinical trial administrative data

CALGB Form
Description

CALGBForm

Type de données

text

CALGB Study No
Description

CALGBStudyNo

Type de données

text

CALGB Patient ID
Description

CALGBPatientID

Type de données

text

Amended data?
Description

Amendeddata?

Type de données

text

Patient demographics
Description

Patient demographics

Patient's Name
Description

Patient'sName

Type de données

text

Participating Group
Description

ParticipatingGroup

Type de données

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Type de données

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Type de données

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Type de données

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Type de données

text

pathology/biopsy status
Description

pathology/biopsy status

Do tissue block/slides accompany this form? (If No,)
Description

Dotissueblock/slidesaccompanythisform?

Type de données

text

specify reason (specimen will not be submitted)
Description

specifyreason(specimenwillnotbesubmitted)

Type de données

text

Is patient enrolled in a correlative science study? (If Yes, give the)
Description

Ispatientenrolledinacorrelativesciencestudy?

Type de données

text

correlative study number(s)
Description

correlativestudynumber(s)

Type de données

text

Surgical Procedure Date (M)
Description

SurgicalProcedureDate

Type de données

text

Date blocks and pathology reports submitted (M)
Description

Dateblocksandpathologyreportssubmitted

Type de données

text

Tissue pathology (mark one with an X)
Description

Tissuepathology

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C12801
UMLS 2011AA ObjectClass
C0040300
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus ObjectClass
C18189
UMLS 2011AA ObjectClass
C0030664
Method of extraction (mark one with an X)
Description

Methodofextraction

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus Property
C15329
UMLS 2011AA Property
C0543467
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Pathology/accession number
Description

Pathology/accessionnumber

Type de données

text

Submitted By (Last Name)
Description

PersonSpecimenSubmittedName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Phone No.
Description

PhoneNo.

Type de données

text

Ccrr Module For Calgb: Tracking Form (tissue Blocks)
Description

Ccrr Module For Calgb: Tracking Form (tissue Blocks)

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Similar models

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Patient demographics
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
pathology/biopsy status
Item
Do tissue block/slides accompany this form? (If No,)
text
CL.2
Code List
Do tissue block/slides accompany this form? (If No,)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
specifyreason(specimenwillnotbesubmitted)
Item
specify reason (specimen will not be submitted)
text
Item
Is patient enrolled in a correlative science study? (If Yes, give the)
text
CL.3
Code List
Is patient enrolled in a correlative science study? (If Yes, give the)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
correlativestudynumber(s)
Item
correlative study number(s)
text
SurgicalProcedureDate
Item
Surgical Procedure Date (M)
text
Dateblocksandpathologyreportssubmitted
Item
Date blocks and pathology reports submitted (M)
text
Item
Tissue pathology (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C18189 (NCI Thesaurus ObjectClass)
C0030664 (UMLS 2011AA ObjectClass)
CL.4
Code List
Tissue pathology (mark one with an X)
CL Item
Primary Tumor (Primary tumor)
CL Item
Recurrent Tumor (Recurrent tumor)
CL Item
Lymph Node Metastasis (Lymph node metastasis)
CL Item
Non-malignant Tissue (Non-malignant tissue)
CL Item
Metastasis (Metastasis)
C19151 (NCI Thesaurus)
C0027627 (UMLS 2011AA)
CL Item
Uninvolved Node (Uninvolved node)
Item
Method of extraction (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C15329 (NCI Thesaurus Property)
C0543467 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
CL.5
Code List
Method of extraction (mark one with an X)
CL Item
Biopsy (Biopsy)
C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)
CL Item
Axillary Dissection (Axillary dissection)
CL Item
Mastectomy (Mastectomy)
C15277 (NCI Thesaurus)
C0024881 (UMLS 2011AA)
CL Item
Re-excision (Re-excision)
C48600 (NCI Thesaurus)
C0184913 (UMLS 2011AA)
CL Item
General Surgery, Nos (General surgery, NOS)
CL Item
Sentinel Node Dissection (Sentinel node dissection)
CL Item
Lumpectomy (Lumpectomy)
C15755 (NCI Thesaurus)
C0024885 (UMLS 2011AA)
Pathology/accessionnumber
Item
Pathology/accession number
text
PersonSpecimenSubmittedName
Item
Submitted By (Last Name)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
PhoneNo.
Item
Phone No.
text
Item Group
Ccrr Module For Calgb: Tracking Form (tissue Blocks)
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