ID

752

Description

SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678B75B-66D7-50A2-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678B75B-66D7-50A2-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 3/22/15 3/22/15 - Martin Dugas
Uploaded on

August 26, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00070564 Pathology - SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM - 2046468v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Unnamed1
Description

Unnamed1

SWOG Patient No.
Description

SWOGPatientID

Data type

text

TREATMENT STUDY NO.
Description

SWOGStudyNo.

Data type

text

Reg Type
Description

RegType

Data type

text

Patient Initials (L, F, M)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Disease
Description

Disease

Data type

text

Institution/Member
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Contact Person at Institution
Description

ContactPersonatInstitution

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
Telephone No. (Groups other than SWOG)
Description

PhoneNumber

Data type

double

Group Name
Description

ParticipatingGroupName

Data type

text

Study No.
Description

Particip.GroupProtocolNumber

Data type

double

Pt. No.
Description

PatientStudyID,ParticipatingGroup

Data type

text

Unnamed2
Description

Unnamed2

Specimen
Description

Specimen

Type of Specimen (Check only one)
Description

TypeofSpecimen

Data type

text

Tissue, specify site(s)
Description

SpecimenSite

Data type

text

Unnamed3 (check one)
Description

SpecimenState

Data type

text

Slides, type and number
Description

Slides,typeandnumber

Data type

text

Karyotype(s), number
Description

KaryotypeCount

Data type

double

Other, specify
Description

SpecimenCellSource,Other

Data type

text

Date specimen collected (month, day, year)
Description

SpecimenCollectionDate

Data type

date

Time specimen collected (Check all that apply)
Description

SpecimenCollectionTime

Data type

date

Reasons For Specimen Submission
Description

Reasons For Specimen Submission

STATUS
Description

STATUS

Data type

text

Other specimen, specify
Description

Otherspecimen,specify

Data type

text

TREATMENT STUDY NO.
Description

SWOGStudyNo.

Data type

text

Unnamed4
Description

Unnamed4

By
Description

PersonCompletingForm,LastName

Data type

text

Date
Description

FormCompletionDate,Original

Data type

date

Unnamed5
Description

Unnamed5

Notes from central laboratory
Description

Comments

Data type

text

Unnamed6
Description

Unnamed6

Central laboratory identification number
Description

Centrallaboratoryidentificationnumber

Data type

text

Date specimen received
Description

SpecimenReceivedDate

Data type

date

Time specimen received
Description

SpecimenReceivedTime

Data type

date

Condition of specimen (check only one)
Description

SpecimenCondition

Data type

text

Unnamed7
Description

Unnamed7

By
Description

PersonCompletingForm,LastName

Data type

text

Date
Description

FormCompletionDate,Original

Data type

date

Unnamed8
Description

Unnamed8

Notes from central laboratory
Description

Comments

Data type

text

Ccrr Module For Southwest Oncology Group Specimen Submission Form
Description

Ccrr Module For Southwest Oncology Group Specimen Submission Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient No.
text
SWOGStudyNo.
Item
TREATMENT STUDY NO.
text
RegType
Item
Reg Type
text
PatientInitialsName
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
Disease
Item
Disease
text
MainMemberInstitution/Affiliate
Item
Institution/Member
text
RegisteredInvestigator
Item
Physician
text
ContactPersonatInstitution
Item
Contact Person at Institution
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
PhoneNumber
Item
Telephone No. (Groups other than SWOG)
double
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
double
PatientStudyID,ParticipatingGroup
Item
Pt. No.
text
Item Group
Unnamed2
Item Group
Specimen
Item
Type of Specimen (Check only one)
text
CL.1
Code List
Type of Specimen (Check only one)
CL Item
Tubes Of Blood (Tubes of blood)
CL Item
Tubes Of Bone Marrow (Tubes of bone marrow)
CL Item
Tubes Of Serum (Tubes of serum)
CL Item
Tissue, Specify Site(s) (Tissue, specify site(s))
CL Item
Slides, Type And Number (Slides, type and number)
CL Item
Karyotype(s), Number (Karyotype(s), number)
CL Item
Other, Specify (Other, specify)
SpecimenSite
Item
Tissue, specify site(s)
text
Item
Unnamed3 (check one)
text
CL.2
Code List
Unnamed3 (check one)
CL Item
Fresh (fresh)
CL Item
Frozen (frozen)
CL267638 (NCI Metathesaurus)
CL Item
Fixed (paraffin embedded)
Slides,typeandnumber
Item
Slides, type and number
text
KaryotypeCount
Item
Karyotype(s), number
double
SpecimenCellSource,Other
Item
Other, specify
text
SpecimenCollectionDate
Item
Date specimen collected (month, day, year)
date
SpecimenCollectionTime
Item
Time specimen collected (Check all that apply)
date
Item Group
Reasons For Specimen Submission
Item
STATUS
text
CL.3
Code List
STATUS
CL Item
Prestudy Specimen (Prestudy specimen)
CL Item
Complete Remission/response Specimen (Complete remission/response specimen)
CL Item
Relapse/recurrence Specimen (Relapse/recurrence specimen)
CL Item
Other Specimen, Specify (Other specimen, specify)
Otherspecimen,specify
Item
Other specimen, specify
text
SWOGStudyNo.
Item
TREATMENT STUDY NO.
text
Item Group
Unnamed4
PersonCompletingForm,LastName
Item
By
text
FormCompletionDate,Original
Item
Date
date
Item Group
Unnamed5
Comments
Item
Notes from central laboratory
text
Item Group
Unnamed6
Centrallaboratoryidentificationnumber
Item
Central laboratory identification number
text
SpecimenReceivedDate
Item
Date specimen received
date
SpecimenReceivedTime
Item
Time specimen received
date
Item
Condition of specimen (check only one)
text
CL.4
Code List
Condition of specimen (check only one)
CL Item
Useable (usable as received)
CL Item
not usable as received; adequate submission (not usable as received; adequate submission)
CL Item
not usable as received; inadequate submission (not usable as received; inadequate submission)
CL Item
Damaged Or Unusable (Damaged or unusable)
CL Item
No Specimen Received (No specimen received)
Item Group
Unnamed7
PersonCompletingForm,LastName
Item
By
text
FormCompletionDate,Original
Item
Date
date
Item Group
Unnamed8
Comments
Item
Notes from central laboratory
text
Item Group
Ccrr Module For Southwest Oncology Group Specimen Submission Form
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