ID

9430

Beschrijving

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

Link

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

Trefwoorden

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

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00090974 Transmittal - WHOLE BLOOD for SERUM/DNA BANKING SUBMISSION REPORT - 2058882v3.0

Engels

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

1 Formulieren  
Patient Information
Beschrijving

Patient Information

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

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Initials (first - middle - last)
Beschrijving

Patient Initials

Datatype

text

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

PatientMedicalRecordNumber

Datatype

text

Investigator Name
Beschrijving

InvestigatorName

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Registered Investigator (NCI Investigator #)
Beschrijving

RegisteredInvestigator

Datatype

text

Whole Blood Submission
Beschrijving

Whole Blood Submission

Specimen Collection Date (Whole Blood in EDTA)
Beschrijving

SpecimenCollectionDate

Datatype

date

Unnamed question (specimen type) (check one)
Beschrijving

SpecimenCollectionPeriodInterval

Datatype

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
Beschrijving

Comments

COMMENTS
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

Investigator Signature

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

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

PersonCompletingForm,LastName

Datatype

text

Person Completing Form, First Name
Beschrijving

PersonCompletingForm,FirstName

Datatype

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)
Beschrijving

FormCompletionDate,Original

Datatype

date

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

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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