ID

9210

Descripción

Pathology Submission Report Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A069EFF3-E6C4-50D8-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A069EFF3-E6C4-50D8-E034-080020C9C0E0

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  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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Lung Cancer NCT00049543 Pathology - Pathology Submission Report - 2034358v3.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: Pathology Submission Report
    1. No Instruction available.
1. Patient Information
Descripción

1. Patient Information

NCIC CTG Patient Serial #
Descripción

PatientStudyID,CoordinatingGroup

Tipo de datos

text

Hospital #
Descripción

PatientMedicalRecordNumber

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
Intergroup Patient Serial #
Descripción

PatientStudyID,ParticipatingGroup

Tipo de datos

text

Site #
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient's Social Security # (USA only)
Descripción

PatientSocialSecurityNumber

Tipo de datos

float

Institution
Descripción

InstitutionName

Tipo de datos

text

Investigator
Descripción

RegisteredInvestigator

Tipo de datos

text

2. Pathology Submission
Descripción

2. Pathology Submission

Date tissue obtained for diagnosis
Descripción

SpecimenCollectionDate

Tipo de datos

date

Name of Institution
Descripción

AddressPathologyInstitutionName

Tipo de datos

text

Address
Descripción

Address

Tipo de datos

text

Contact Pathologist Name
Descripción

PathologistName,Reviewing

Tipo de datos

text

Pathology specimen number(s)
Descripción

SpecimenID

Tipo de datos

float

3. Comments
Descripción

3. Comments

3. COMMENTS
Descripción

Comments

Tipo de datos

text

4. Investigator Signature
Descripción

4. Investigator Signature

Signature of Responsible Investigator
Descripción

InvestigatorSignature

Tipo de datos

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Name of Clinical Research Associate
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Date
Descripción

FormCompletionDate,Original

Tipo de datos

date

Ncic Ctg Use Only
Descripción

Ncic Ctg Use Only

Logged
Descripción

LoggedEntryInitials

Tipo de datos

text

Header
Descripción

LoggedEntryDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Study Coord
Descripción

CoordinatorReviewInitials

Tipo de datos

text

Unnamed2
Descripción

CoordinatorReviewDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Phy
Descripción

PhysicianReviewInitials

Tipo de datos

text

Data Ent'd
Descripción

DataEntryInitials

Tipo de datos

text

Verified
Descripción

DataVerificationInitials

Tipo de datos

text

Ccrr Module For Pathology Submission Report
Descripción

Ccrr Module For Pathology Submission Report

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
Address, Department
Descripción

AddressPathologyDepartment

Tipo de datos

text

Address, Street
Descripción

AddressPathologyStreet

Tipo de datos

text

Address Postal Code
Descripción

AddressPathologyPostalCode

Tipo de datos

text

Address Province
Descripción

AddressPathologyProvince

Tipo de datos

text

Address Country
Descripción

AddressPathologyCountry

Tipo de datos

text

Address City
Descripción

AddressPathologyCity

Tipo de datos

text

State
Descripción

State

Tipo de datos

text

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: Pathology Submission Report
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
1. Patient Information
PatientStudyID,CoordinatingGroup
Item
NCIC CTG Patient Serial #
text
PatientMedicalRecordNumber
Item
Hospital #
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)
PatientStudyID,ParticipatingGroup
Item
Intergroup Patient Serial #
text
NCIInstitutionNumber
Item
Site #
text
PatientSocialSecurityNumber
Item
Patient's Social Security # (USA only)
float
InstitutionName
Item
Institution
text
RegisteredInvestigator
Item
Investigator
text
Item Group
2. Pathology Submission
SpecimenCollectionDate
Item
Date tissue obtained for diagnosis
date
AddressPathologyInstitutionName
Item
Name of Institution
text
Address
Item
Address
text
PathologistName,Reviewing
Item
Contact Pathologist Name
text
SpecimenID
Item
Pathology specimen number(s)
float
Item Group
3. Comments
Comments
Item
3. COMMENTS
text
Item Group
4. Investigator Signature
InvestigatorSignature
Item
Signature of Responsible Investigator
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Name of Clinical Research Associate
text
FormCompletionDate,Original
Item
Date
date
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Header
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Unnamed2
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Ccrr Module For Pathology Submission Report
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)
AddressPathologyDepartment
Item
Address, Department
text
AddressPathologyStreet
Item
Address, Street
text
AddressPathologyPostalCode
Item
Address Postal Code
text
AddressPathologyProvince
Item
Address Province
text
AddressPathologyCountry
Item
Address Country
text
AddressPathologyCity
Item
Address City
text
State
Item
State
text
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