ID

9395

Descripción

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

Palabras clave

Versiones (3)
  1. 26/8/12 26/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 22/3/15 22/3/15 - Martin Dugas
Subido en

9 de enero de 2015

DOI

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Licencia

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

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Header
Descripción

Header

SWOG Patient No.
Descripción

SWOGPatientID

Tipo de datos

text

TREATMENT STUDY NO.
Descripción

SWOGStudyNo.

Tipo de datos

text

Reg Type
Descripción

RegType

Tipo de datos

text

Patient Initials (L, F, M)
Descripción

Patient Initials

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Disease
Descripción

Disease

Tipo de datos

text

Institution/Member
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician
Descripción

RegisteredInvestigator

Tipo de datos

text

Contact Person at Institution
Descripción

ContactPersonatInstitution

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C25461
UMLS 2011AA ObjectClass-2
C0337611
Telephone No. (Groups other than SWOG)
Descripción

PhoneNumber

Tipo de datos

float

Group Name
Descripción

ParticipatingGroupName

Tipo de datos

text

Study No.
Descripción

Particip.GroupProtocolNumber

Tipo de datos

float

Pt. No.
Descripción

PatientStudyID,ParticipatingGroup

Tipo de datos

text

Unnamed2
Descripción

Unnamed2

Specimen
Descripción

Specimen

Type of Specimen (Check only one)
Descripción

TypeofSpecimen

Tipo de datos

text

Tissue, specify site(s)
Descripción

SpecimenSite

Tipo de datos

text

Unnamed3 (check one)
Descripción

SpecimenState

Tipo de datos

text

Slides, type and number
Descripción

Slides,typeandnumber

Tipo de datos

text

Karyotype(s), number
Descripción

KaryotypeCount

Tipo de datos

float

Other, specify
Descripción

SpecimenCellSource,Other

Tipo de datos

text

Date specimen collected (month, day, year)
Descripción

SpecimenCollectionDate

Tipo de datos

date

Time specimen collected (Check all that apply)
Descripción

SpecimenCollectionTime

Tipo de datos

date

Reasons For Specimen Submission
Descripción

Reasons For Specimen Submission

STATUS
Descripción

STATUS

Tipo de datos

text

Other specimen, specify
Descripción

Otherspecimen,specify

Tipo de datos

text

TREATMENT STUDY NO.
Descripción

SWOGStudyNo.

Tipo de datos

text

Unnamed4
Descripción

Unnamed4

By
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Date
Descripción

FormCompletionDate,Original

Tipo de datos

date

Unnamed5
Descripción

Unnamed5

Notes from central laboratory
Descripción

Comments

Tipo de datos

text

Unnamed6
Descripción

Unnamed6

Central laboratory identification number
Descripción

Centrallaboratoryidentificationnumber

Tipo de datos

text

Date specimen received
Descripción

SpecimenReceivedDate

Tipo de datos

date

Time specimen received
Descripción

SpecimenReceivedTime

Tipo de datos

date

Condition of specimen (check only one)
Descripción

SpecimenCondition

Tipo de datos

text

Unnamed7
Descripción

Unnamed7

By
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Date
Descripción

FormCompletionDate,Original

Tipo de datos

date

Unnamed8
Descripción

Unnamed8

Notes from central laboratory
Descripción

Comments

Tipo de datos

text

Ccrr Module For Southwest Oncology Group Specimen Submission Form
Descripción

Ccrr Module For Southwest Oncology Group Specimen Submission Form

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient No.
text
SWOGStudyNo.
Item
TREATMENT STUDY NO.
text
RegType
Item
Reg Type
text
Patient Initials
Item
Patient Initials (L, F, M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus 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-2)
C0337611 (UMLS 2011AA ObjectClass-2)
PhoneNumber
Item
Telephone No. (Groups other than SWOG)
float
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
float
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
float
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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