ID

11612

Description

NCT00890747 AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Sunitinib Malate in Treating HIV-Positive Patients With Cancer Undergoing Highly Active Antiretroviral Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 7/8/15 7/8/15 -
  3. 7/8/15 7/8/15 -
Uploaded on

July 8, 2015

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00890747 AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Header Module
Description

Header Module

Visit number
Description

Visit number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI-1
C1549755
Study Coordinator's name
Description

Study Coordinator's name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C51880
UMLS CUI-1
C1515830
UMLS CUI-2
C1710220
E-mail
Description

E-mail

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C42775
UMLS CUI-1
C1705961
Phone Number (xxx-xxx-xxxx)
Description

Phone Number (xxx-xxx-xxxx)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25395
NCI Thesaurus ObjectClass
C19711
UMLS CUI-1
C0039457
Specimen information
Description

Specimen information

Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
Description

Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25452
NCI Thesaurus Property-2
C25275
UMLS CUI-1
C0011008
UMLS CUI-2
C0370003
Specimen(s) obtained for donation to ACSR
Description

Specimen(s) obtained for donation to ACSR

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI-1
C0370003
UMLS CUI-2
C1515830
Specimen Type (check all that apply)
Description

Specimen Type (check all that apply)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25695
UMLS CUI-1
C0370003
UMLS CUI-2
C1515023
Other specify
Description

Other specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C12508
NCI Thesaurus Property-2
C25683
NCI Thesaurus ObjectClass
C19157
UMLS CUI-1
C1521902
UMLS CUI-2
C0370003
ACSR site the specimen(s) shipped to
Description

ACSR site the specimen(s) shipped to

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI-1
C1515830
UMLS CUI-2
C1524049
Other, specify
Description

Other, specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI-1
C1521902
UMLS CUI-2
C0370003
If specimens were not obtained for ACSR, please indicate reason
Description

If specimens were not obtained for ACSR, please indicate reason

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C25594
NCI Thesaurus Property-2
C25695
NCI Thesaurus ValueDomain
C25638
UMLS CUI-1
C1515830
UMLS CUI-2
C0392360
Other, specify
Description

Other, specify

Data type

text

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C25594
NCI Thesaurus Property-2
C25695
NCI Thesaurus ValueDomain
C25685
UMLS CUI-1
C0370003
UMLS CUI-2
C1521902
Comments
Description

Comments

Comments
Description

Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI-1
C0282411
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Visit number
Item
Visit number
text
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI-1)
Study Coordinator's name
Item
Study Coordinator's name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C51880 (NCI Thesaurus Property)
C1515830 (UMLS CUI-1)
C1710220 (UMLS CUI-2)
Responsible Person E-mail
Item
E-mail
text
C25704 (NCI Thesaurus ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS CUI-1)
Organization Phone Number
Item
Phone Number (xxx-xxx-xxxx)
text
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus Property)
C19711 (NCI Thesaurus ObjectClass)
C0039457 (UMLS CUI-1)
Item Group
Specimen information
Specimen Collected Date
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C0011008 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
AIDS Malignancy Specimen Procurement
Item
Specimen(s) obtained for donation to ACSR
boolean
C38147 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0370003 (UMLS CUI-1)
C1515830 (UMLS CUI-2)
Item
Specimen Type (check all that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C0370003 (UMLS CUI-1)
C1515023 (UMLS CUI-2)
CL.2
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
C13325 (NCI Thesaurus)
C13325 (NCI Thesaurus-3)
C0229671 (UMLS CUI-1)
CL Item
Plasma (Plasma)
C13356 (NCI Thesaurus)
C13356 (NCI Thesaurus-3)
C0032105 (UMLS CUI-1)
CL Item
peripheral Blood Mononuclear Cells (PBMC)
C1321301 (UMLS CUI-1)
CL Item
Peripheral Blood (Blood)
C0229664 (NCI Metathesaurus)
C0229664 (NCI Metathesaurus-2)
C0229664 (UMLS CUI-1)
CL Item
Tissue (Tissue)
C12801 (NCI Thesaurus)
C0040300 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
Specimen Cell Source Specify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C12508 (NCI Thesaurus Property)
C25683 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus ObjectClass)
C1521902 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
Item
ACSR site the specimen(s) shipped to
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C1515830 (UMLS CUI-1)
C1524049 (UMLS CUI-2)
CL.3
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucla (UCLA)
C1517622 (UMLS CUI-1)
CL Item
Ucsf (UCSF)
C1515354 (UMLS CUI-1)
CL Item
Osu (OSU)
CL Item
Suny/hscb (SUNY/HSCB)
CL Item
Jhu (JHU)
C3828025 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
AIDS Malignancy Consortium Specimen Specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C1521902 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
Item
If specimens were not obtained for ACSR, please indicate reason
text
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25638 (NCI Thesaurus ValueDomain)
C1515830 (UMLS CUI-1)
C0392360 (UMLS CUI-2)
CL.4
Code List
If specimens were not obtained for ACSR, please indicate reason
CL Item
Patient Had Previously Donated Specimen To Acsr (Patient had previously donated specimen to ACSR)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused to give informed consent for ACSR specimen donation)
CL Item
Patient Was Not Asked To Consider Acsr Specimen Donation (Patient was not asked to consider ACSR specimen donation)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AIDS Malignancy Consortium Not Submitted Specify
Item
Other, specify
text
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
C0370003 (UMLS CUI-1)
C1521902 (UMLS CUI-2)
Item Group
Comments
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS CUI-1)
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