ID

752

Beschrijving

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

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 22-03-15 22-03-15 - Martin Dugas
Geüploaded op

26 augustus 2012

DOI

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Licentie

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

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

SWOG Patient No.
Beschrijving

SWOGPatientID

Datatype

text

TREATMENT STUDY NO.
Beschrijving

SWOGStudyNo.

Datatype

text

Reg Type
Beschrijving

RegType

Datatype

text

Patient Initials (L, F, M)
Beschrijving

PatientInitialsName

Datatype

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
Beschrijving

Disease

Datatype

text

Institution/Member
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
Beschrijving

RegisteredInvestigator

Datatype

text

Contact Person at Institution
Beschrijving

ContactPersonatInstitution

Datatype

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)
Beschrijving

PhoneNumber

Datatype

double

Group Name
Beschrijving

ParticipatingGroupName

Datatype

text

Study No.
Beschrijving

Particip.GroupProtocolNumber

Datatype

double

Pt. No.
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Specimen
Beschrijving

Specimen

Type of Specimen (Check only one)
Beschrijving

TypeofSpecimen

Datatype

text

Tissue, specify site(s)
Beschrijving

SpecimenSite

Datatype

text

Unnamed3 (check one)
Beschrijving

SpecimenState

Datatype

text

Slides, type and number
Beschrijving

Slides,typeandnumber

Datatype

text

Karyotype(s), number
Beschrijving

KaryotypeCount

Datatype

double

Other, specify
Beschrijving

SpecimenCellSource,Other

Datatype

text

Date specimen collected (month, day, year)
Beschrijving

SpecimenCollectionDate

Datatype

date

Time specimen collected (Check all that apply)
Beschrijving

SpecimenCollectionTime

Datatype

date

Reasons For Specimen Submission
Beschrijving

Reasons For Specimen Submission

STATUS
Beschrijving

STATUS

Datatype

text

Other specimen, specify
Beschrijving

Otherspecimen,specify

Datatype

text

TREATMENT STUDY NO.
Beschrijving

SWOGStudyNo.

Datatype

text

Unnamed4
Beschrijving

Unnamed4

By
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Date
Beschrijving

FormCompletionDate,Original

Datatype

date

Unnamed5
Beschrijving

Unnamed5

Notes from central laboratory
Beschrijving

Comments

Datatype

text

Unnamed6
Beschrijving

Unnamed6

Central laboratory identification number
Beschrijving

Centrallaboratoryidentificationnumber

Datatype

text

Date specimen received
Beschrijving

SpecimenReceivedDate

Datatype

date

Time specimen received
Beschrijving

SpecimenReceivedTime

Datatype

date

Condition of specimen (check only one)
Beschrijving

SpecimenCondition

Datatype

text

Unnamed7
Beschrijving

Unnamed7

By
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Date
Beschrijving

FormCompletionDate,Original

Datatype

date

Unnamed8
Beschrijving

Unnamed8

Notes from central laboratory
Beschrijving

Comments

Datatype

text

Ccrr Module For Southwest Oncology Group Specimen Submission Form
Beschrijving

Ccrr Module For Southwest Oncology Group Specimen Submission Form

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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