ID

699

Beschrijving

CALGB: SPECIMEN ROUTING FORM PLASMA Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-82EA-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-82EA-227A-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 22-05-15 22-05-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

26 augustus 2012

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Breast Cancer NCT00016276 Pathology - CALGB: SPECIMEN ROUTING FORM PLASMA - 2032060v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM PLASMA
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBProtocolNumber

Datatype

text

CALGB Patient ID
Beschrijving

CALGBPatientID

Datatype

text

Amended data?
Beschrijving

AmendedDataInd

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Beschrijving

Unnamed2

Patient's Name
Beschrijving

Patient'sName

Datatype

text

Patient Hospital Number
Beschrijving

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Adjunct

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientNo.

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

To Be Completed By Submitting Institution
Beschrijving

To Be Completed By Submitting Institution

Blood Sample (plasma)
Beschrijving

BloodSample

Datatype

text

Date plasma specimen collected
Beschrijving

Dateplasmaspecimencollected

Datatype

text

CALGB Treatment Study
Beschrijving

CALGBTreatmentStudy

Datatype

text

Does specimen accompany this form? (If yes, complete the remainder of this form.)
Beschrijving

Specimenw/FormInd

Datatype

text

Number of tubes submitted
Beschrijving

Numberoftubessubmitted

Datatype

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C41277
UMLS 2011AA ObjectClass
C1561954
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Date sample sent
Beschrijving

Datesamplesent

Datatype

text

Time Period Specimen Collected (mark one with an X)
Beschrijving

TimePeriodSpecimenCollected

Datatype

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25452
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
NCI Thesaurus ValueDomain
C25452
Responsible treating physician
Beschrijving

Responsibletreatingphysician:

Datatype

text

Phone Number to be used in event of sample problems
Beschrijving

PhoneNumbertobeusedineventofsampleproblems:

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C40978
UMLS 2011AA Property
C1515258
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If no, specify reason
Beschrijving

Ifno,specifyreason

Datatype

text

Completed By
Beschrijving

CompletedBy

Datatype

text

Date Completed
Beschrijving

DateCompleted

Datatype

text

To Be Completed By Receiving Institution/laboratory
Beschrijving

To Be Completed By Receiving Institution/laboratory

Date sample received
Beschrijving

Datesamplereceived

Datatype

text

Sample Condition (mark one with an X)
Beschrijving

SampleCondition

Datatype

text

Alias
NCI Thesaurus ObjectClass
C12801
UMLS 2011AA ObjectClass
C0040300
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25457
UMLS 2011AA Property
C0348080
Sample ID no.
Beschrijving

SpecimenID

Datatype

double

Number of Aliquots
Beschrijving

NumberofAliquots

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
Average aliquot volume (cc)
Beschrijving

Averagealiquotvolume

Datatype

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25335
UMLS 2011AA Property
C0449468
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain
C37917
UMLS 2011AA ValueDomain
C1510992
Sample received by
Beschrijving

Samplereceivedby

Datatype

text

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM PLASMA
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
Patient'sName
Item
Patient's Name
text
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
ParticipatingGroup
Item
Participating Group
text
Item Group
To Be Completed By Submitting Institution
BloodSample
Item
Blood Sample (plasma)
text
Dateplasmaspecimencollected
Item
Date plasma specimen collected
text
CALGBTreatmentStudy
Item
CALGB Treatment Study
text
Item
Does specimen accompany this form? (If yes, complete the remainder of this form.)
text
CL.2
Code List
Does specimen accompany this form? (If yes, complete the remainder of this form.)
CL Item
No (No)
CL Item
Yes (Yes)
Numberoftubessubmitted
Item
Number of tubes submitted
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C41277 (NCI Thesaurus ObjectClass)
C1561954 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
Datesamplesent
Item
Date sample sent
text
Item
Time Period Specimen Collected (mark one with an X)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25452 (NCI Thesaurus Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C25452 (NCI Thesaurus ValueDomain)
CL.3
Code List
Time Period Specimen Collected (mark one with an X)
CL Item
Pre-treatment (Pre-treatment)
CL Item
During Initial Treatment (During Initial Treatment)
CL Item
During Follow-up, No. Therapy (During Follow-Up, No. Therapy)
CL Item
At Relapse/progression (At Relapse/Progression)
Responsibletreatingphysician:
Item
Responsible treating physician
text
PhoneNumbertobeusedineventofsampleproblems:
Item
Phone Number to be used in event of sample problems
text
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C40978 (NCI Thesaurus Property)
C1515258 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Ifno,specifyreason
Item
If no, specify reason
text
CompletedBy
Item
Completed By
text
DateCompleted
Item
Date Completed
text
Item Group
To Be Completed By Receiving Institution/laboratory
Datesamplereceived
Item
Date sample received
text
Item
Sample Condition (mark one with an X)
text
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25457 (NCI Thesaurus Property)
C0348080 (UMLS 2011AA Property)
CL.4
Code List
Sample Condition (mark one with an X)
CL Item
Okay (Okay)
CL Item
Damaged (Damaged)
CL Item
Missing (Missing)
C54031 (NCI Thesaurus)
C1705492 (UMLS 2011AA)
CL Item
Insufficient Amount (Insufficient amount)
CL Item
Damaged But Stored (Damaged but stored)
CL Item
Thawed But Stored (Thawed but stored)
CL Item
Improperly Stored (Improperly stored)
SpecimenID
Item
Sample ID no.
double
NumberofAliquots
Item
Number of Aliquots
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
Averagealiquotvolume
Item
Average aliquot volume (cc)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25335 (NCI Thesaurus Property)
C0449468 (UMLS 2011AA Property)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C37917 (NCI Thesaurus ValueDomain)
C1510992 (UMLS 2011AA ValueDomain)
Samplereceivedby
Item
Sample received by
text
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial