ID

9430

Description

WHOLE BLOOD for SERUM/DNA BANKING 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=ABE25A45-A7B6-53B4-E034-0003BA12F5E7

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE25A45-A7B6-53B4-E034-0003BA12F5E7

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

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Breast Cancer NCT00090974 Transmittal - WHOLE BLOOD for SERUM/DNA BANKING SUBMISSION REPORT - 2058882v3.0

Anglais

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

1 Formulaires  
Patient Information
Description

Patient Information

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

PatientStudyID,CoordinatingGroup

Type de données

text

Patient Initials (first - middle - last)
Description

Patient Initials

Type de données

text

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

PatientMedicalRecordNumber

Type de données

text

Investigator Name
Description

InvestigatorName

Type de données

text

Institution Name
Description

InstitutionName

Type de données

text

Registered Investigator (NCI Investigator #)
Description

RegisteredInvestigator

Type de données

text

Whole Blood Submission
Description

Whole Blood Submission

Specimen Collection Date (Whole Blood in EDTA)
Description

SpecimenCollectionDate

Type de données

date

Unnamed question (specimen type) (check one)
Description

SpecimenCollectionPeriodInterval

Type de données

text

Alias
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property-2
C25453
UMLS 2011AA Property-2
C1516698
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ValueDomain
C25543
UMLS 2011AA ValueDomain
C1272706
Comments
Description

Comments

COMMENTS
Description

Comments

Type de données

text

Investigator Signature
Description

Investigator Signature

Investigator Signature
Description

InvestigatorSignature

Type de données

text

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

PersonCompletingForm,LastName

Type de données

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Type de données

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)
Description

FormCompletionDate,Original

Type de données

date

Ccrr Module For Whole Blood For Serum/dna Banking Submission Report
Description

Ccrr Module For Whole Blood For Serum/dna Banking Submission Report

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Similar models

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

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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
Whole Blood Submission
SpecimenCollectionDate
Item
Specimen Collection Date (Whole Blood in EDTA)
date
Item
Unnamed question (specimen type) (check one)
text
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25453 (NCI Thesaurus Property-2)
C1516698 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25543 (NCI Thesaurus ValueDomain)
C1272706 (UMLS 2011AA ValueDomain)
CL.1
Code List
Unnamed question (specimen type) (check one)
CL Item
Baseline Specimen (Baseline Specimen)
CL Item
6-month Specimen (6-month Specimen)
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 Whole Blood For Serum/dna Banking Submission Report
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