Pathology Procurement Form AIDS and Cancer Specimen Resource (ACSR F37 AMC-058 NCT00695422)

AMC-058 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Detecting Anal and Genital Human Papillomavirus Infection and Squamous Intraepithelial Lesions in HIV-Positive Patients Enrolled in AIDS Cancer Clinical Trials NCT00695422 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84983DFF-51D6-D314-E040-BB89AD432101

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  1. StudyEvent: AMC-058 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Visit number
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI-1)
Study Coordinator
Item
Study Coordinator's name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C51880 (NCI Thesaurus Property)
C1710220 (UMLS CUI-1)
Email
Item
E-mail
text
C25704 (NCI Thesaurus ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS CUI-1)
Phone number
Item
Phone Number
text
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus Property)
C19711 (NCI Thesaurus ObjectClass)
C0039457 (UMLS CUI-1)
Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI-1)
Item Group
Specimen Procurement
C0370003 (UMLS CUI-1)
C1709695 (UMLS CUI-2)
Collection Date
Item
Date Specimen Obtained
date
C25164 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C1317250 (UMLS CUI-1)
Specimen donation
Item
Specimen(s) obtained for donation to ACSR
boolean
C38147 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0080231 (UMLS CUI-1)
Item
Specimen Type
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C2347029 (UMLS CUI-1)
Code List
Specimen Type
CL Item
Serum (Serum)
C13325 (NCI Thesaurus)
C13325 (NCI Thesaurus-3)
C0229671 (UMLS CUI-1)
CL Item
Plasma (Plasma)
C13356 (NCI Thesaurus)
C13356 (NCI Thesaurus-3)
C0032105 (UMLS CUI-1)
CL Item
PBMC (peripheral Blood Mononuclear Cells) (PBMC)
C1321301 (UMLS CUI-1)
CL Item
Peripheral Blood (Blood)
C0229664 (NCI Metathesaurus)
C0229664 (NCI Metathesaurus-2)
C0229664 (UMLS CUI-1)
CL Item
Tissue (Tissue)
C12801 (NCI Thesaurus)
C0040300 (UMLS CUI-1)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
Specimen cell source
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C12508 (NCI Thesaurus Property)
C25683 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS CUI-1)
C0449416 (UMLS CUI-2)
Item
ACSR site the specimen(s) shipped to
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0022877 (UMLS CUI-1)
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucla (UCLA)
CL Item
Ucsf (UCSF)
CL Item
Osu (OSU)
CL Item
Suny/hscb (SUNY/HSCB)
CL Item
Jhu (JHU)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other, specify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
Item
If specimens were not obtained for ACSR, please indicate reason
integer
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25638 (NCI Thesaurus ValueDomain)
C0566251 (UMLS CUI-1)
Code List
If specimens were not obtained for ACSR, please indicate reason
CL Item
Patient Had Previously Donated Specimen To Acsr (1)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (2)
CL Item
Patient Was Not Asked To Consider Acsr Specimen Donation (3)
CL Item
Other (4)
Other, specify
Item
Other, specify
text
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)

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