Breast Cancer NCT00090974 Transmittal - PATHOLOGY SUBMISSION REPORT - 2059549v3.0

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

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

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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