ID

9403

Descripción

PATHOLOGY SUBMISSION REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE248E1-B493-53AD-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE248E1-B493-53AD-E034-0003BA12F5E7

Palabras clave

  1. 26/8/12 26/8/12 -
  2. 9/1/15 9/1/15 - 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 NCT00090974 Transmittal - PATHOLOGY SUBMISSION REPORT - 2059549v3.0

To be submitted with Form 1 - Eligibility Checklist and Initial Evaluation within 6 weeks of randomization

Patient Information
Descripción

Patient Information

Patient Study ID, Coordinating Group (NCIC CTG Patient Serial Number)
Descripción

PatientStudyID,CoordinatingGroup

Tipo de datos

text

Patient Initials (first - middle - last)
Descripción

Patient Initials

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Descripción

PatientMedicalRecordNumber

Tipo de datos

text

Investigator Name
Descripción

InvestigatorName

Tipo de datos

text

Institution Name
Descripción

InstitutionName

Tipo de datos

text

Registered Investigator (NCI Investigator #)
Descripción

RegisteredInvestigator

Tipo de datos

text

Pathology Submission
Descripción

Pathology Submission

Specimen Collection Date - Pathology (yyyy mmm dd)
Descripción

SpecimenCollectionDate

Tipo de datos

date

Pathology Institution Name (at which the pathology specimens are held)
Descripción

AddressPathologyInstitutionName

Tipo de datos

text

Address: Dept./Building
Descripción

AddressPathologyDepartment

Tipo de datos

text

Street name and Number
Descripción

AddressPathologyStreet

Tipo de datos

text

City
Descripción

Address,City

Tipo de datos

text

State/Province
Descripción

AddressPathologyProvince

Tipo de datos

text

Country
Descripción

AddressPathologyCountry

Tipo de datos

text

Postal Code
Descripción

AddressPathologyPostalCode

Tipo de datos

text

Reviewing Pathologist (Diagnosing Pathologists)
Descripción

PathologistName,Reviewing

Tipo de datos

text

Specimen ID number (Pathology accession number #)
Descripción

SpecimenID

Tipo de datos

float

Comments
Descripción

Comments

COMMENTS
Descripción

Comments

Tipo de datos

text

Investigator Signature
Descripción

Investigator Signature

Investigator Signature
Descripción

InvestigatorSignature

Tipo de datos

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Person Completing Form, First Name
Descripción

PersonCompletingForm,FirstName

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Descripción

FormCompletionDate,Original

Tipo de datos

date

Ccrr Module For Pathology Submission Report
Descripción

Ccrr Module For Pathology Submission Report

Similar models

To be submitted with Form 1 - Eligibility Checklist and Initial Evaluation within 6 weeks of randomization

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group (NCIC CTG Patient Serial Number)
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InvestigatorName
Item
Investigator Name
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Pathology Submission
SpecimenCollectionDate
Item
Specimen Collection Date - Pathology (yyyy mmm dd)
date
AddressPathologyInstitutionName
Item
Pathology Institution Name (at which the pathology specimens are held)
text
AddressPathologyDepartment
Item
Address: Dept./Building
text
AddressPathologyStreet
Item
Street name and Number
text
Address,City
Item
City
text
AddressPathologyProvince
Item
State/Province
text
AddressPathologyCountry
Item
Country
text
AddressPathologyPostalCode
Item
Postal Code
text
PathologistName,Reviewing
Item
Reviewing Pathologist (Diagnosing Pathologists)
text
SpecimenID
Item
Specimen ID number (Pathology accession number #)
float
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Pathology Submission Report

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