ID

6198

Description

AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Mots-clés

  1. 18/12/2014 18/12/2014 - Martin Dugas
Téléchargé le

18 décembre 2014

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy

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AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) 3369057v1.0

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Description

HospitalAdmissionOrdinalNumber

Type de données

double

Specimen Procurement
Description

Specimen Procurement

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

SpecimenCollectedDate

Type de données

date

Specimen(s) obtained for donation to ACSR
Description

AIDSMalignancyConsortiumSpecimenProcurementInd-2

Type de données

boolean

Specimen Type (check all that apply)
Description

SpecimenSubmittedType

Type de données

text

Other specify
Description

SpecimenCellSourceSpecify

Type de données

text

ACSR site the specimen(s) shipped to
Description

AIDSMalignancyConsortiumSpecimenProcurementType

Type de données

text

Other, specify
Description

AIDSMalignancyConsortiumSpecimenProcurementSpecify

Type de données

text

If specimens were not obtained for ACSR, please indicate reason
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedReason

Type de données

text

Other, specify
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify

Type de données

text

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

SpecimenCollectedDate

Type de données

date

Study Coordinator
Description

Study Coordinator

Study Coordinator's name
Description

AIDSMalignancyConsortiumPersonStudyCoordinatorName

Type de données

text

E-mail
Description

ResponsiblePersonE-mailAddressText

Type de données

text

Phone Number (xxx-xxx-xxxx)
Description

OrganizationPhoneNumber

Type de données

text

Comments
Description

Comments

Comments
Description

ResearchCommentsText

Type de données

text

Similar models

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
HospitalAdmissionOrdinalNumber
Item
Visit number
double
Item Group
Specimen Procurement
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
AIDSMalignancyConsortiumSpecimenProcurementInd-2
Item
Specimen(s) obtained for donation to ACSR
boolean
Item
Specimen Type (check all that apply)
text
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
CL Item
Plasma (Plasma)
CL Item
Pbmc (peripheral Blood Mononuclear Cells) (PBMC)
CL Item
Peripheral Blood (Blood)
CL Item
Tissue (Tissue)
CL Item
Other (Other)
SpecimenCellSourceSpecify
Item
Other specify
text
Item
ACSR site the specimen(s) shipped to
text
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucsf (UCSF)
CL Item
Jhu (JHU)
CL Item
Other (Other)
AIDSMalignancyConsortiumSpecimenProcurementSpecify
Item
Other, specify
text
Item
If specimens were not obtained for ACSR, please indicate reason
text
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)
AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify
Item
Other, specify
text
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
Item Group
Study Coordinator
AIDSMalignancyConsortiumPersonStudyCoordinatorName
Item
Study Coordinator's name
text
ResponsiblePersonE-mailAddressText
Item
E-mail
text
OrganizationPhoneNumber
Item
Phone Number (xxx-xxx-xxxx)
text
Item Group
Comments
ResearchCommentsText
Item
Comments
text

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