ID

10283

Description

ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC84B74E-4F5E-6306-E034-0003BA12F5E7

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC84B74E-4F5E-6306-E034-0003BA12F5E7

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Versions (2)
  1. 8/27/12 8/27/12 -
  2. 5/22/15 5/22/15 -
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May 22, 2015

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Creative Commons BY-NC 3.0 Legacy
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ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)

English

Form No. 638

1 forms  
  1. StudyEvent: ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
    1. Form No. 638
Part A
Description

Part A

Date Sample Sent to ECOG (M,D,Y)
Description

DateSampleSenttoECOG

Data type

date

Data Manager
Description

DataManager

Data type

text

Telephone No.
Description

TelephoneNo.

Data type

double

FAX No.
Description

FAXNo.

Data type

double

ECOG Parent Prot. No.
Description

ECOGParentProt.No.

Data type

text

Seq. No.
Description

Seq.No.

Data type

text

Patient's Name
Description

Patient'sName

Data type

text

ECOG Prot. No.
Description

ECOGProt.No.

Data type

text

ECOG Patient Seq. No.
Description

ECOGPatientSeq.No.

Data type

text

Participating Group Prot. No.
Description

ParticipatingGroupProt.No.

Data type

text

Participating Group Patient ID No.
Description

ParticipatingGroupPatientIDNo.

Data type

text

Group
Description

Group

Data type

text

Institution
Description

Institution

Data type

text

Step No.
Description

StepNo.

Data type

text

Affiliate (COMPLETE FOR SLIDES)
Description

AffiliateName

Data type

text

Part B
Description

Part B

STATUS (See Below)
Description

STATUS

Data type

text

STATUS (See Below)
Description

STATUS

Data type

text

Other, Specify (specimen status)
Description

Other,Specify(specimenstatus)

Data type

text

Other, Specify (specimen status)
Description

Other,Specify(specimenstatus)

Data type

text

DATE SPECIMEN COLLECTED (M,D,Y)
Description

DATESPECIMENCOLLECTED

Data type

date

DATE SPECIMEN COLLECTED (M,D,Y)
Description

DATESPECIMENCOLLECTED

Data type

date

Telephone No.
Description

TelephoneNo.

Data type

double

DISEASE SITE
Description

DISEASESITE

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
DISEASE SITE
Description

DISEASESITE

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NUMBER OF SLIDES
Description

NUMBEROFSLIDES

Data type

text

TYPE OF STAIN
Description

TYPEOFSTAIN

Data type

text

SPECIMEN ID NUMBERS
Description

SPECIMENIDNUMBERS

Data type

text

SPECIMEN ID NUMBERS
Description

SPECIMENIDNUMBERS

Data type

text

NUMBER OF BLOCKS
Description

NUMBEROFBLOCKS

Data type

text

TYPE OF FIXATIVE
Description

TYPEOFFIXATIVE

Data type

text

Submitting Pathologist
Description

SubmittingPathologist

Data type

text

Address
Description

Address

Data type

text

INSTITUTION COMMENTS
Description

INSTITUTIONCOMMENTS

Data type

text

Can this sample be retained by the ECOG Central Tissue Repository? (NOTE: Samples submitted for protocols requiring submission for tissue banking will not be returned except for purposes of individual patient management. For this reason, the submitting pathologist should retain at least one paraffin block at their institution. )
Description

CanthissampleberetainedbytheECOGCentralTissueRepository?

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
A block has been retained at the submitting institution
Description

Ablockhasbeenretainedatthesubmittinginstitution

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Please CIRCLE THE REASON for non-submission (and INCLUDE a formal letter of explanation)
Description

PleaseCIRCLETHEREASONfornon-submission

Data type

text

specify other (reason for non-submission)
Description

specifyother(reasonfornon-submission)

Data type

text

Pathologist or Investigator's Signature
Description

PathologistorInvestigator'sSignature

Data type

text

Part C
Description

Part C

Date Sample Received by ECOG (M D Y )
Description

DateSampleReceivedbyECOG

Data type

date

Date Sent to Central Lab (M D Y )
Description

DateSenttoCentralLab

Data type

date

Date Sample Sent to Reviewer (M D Y )
Description

DateSampleSenttoReviewer

Data type

date

Items Received (if different from above)
Description

ItemsReceived

Data type

text

Name of Reviewer
Description

NameofReviewer

Data type

text

NOTES
Description

Notes

Data type

text

Ccrr Module For Ecog Pathology Material Submission Form (e2100)
Description

Ccrr Module For Ecog Pathology Material Submission Form (e2100)

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Similar models

Form No. 638

1 forms
  1. StudyEvent: ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
    1. Form No. 638
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Part A
DateSampleSenttoECOG
Item
Date Sample Sent to ECOG (M,D,Y)
date
DataManager
Item
Data Manager
text
TelephoneNo.
Item
Telephone No.
double
FAXNo.
Item
FAX No.
double
ECOGParentProt.No.
Item
ECOG Parent Prot. No.
text
Seq.No.
Item
Seq. No.
text
Patient'sName
Item
Patient's Name
text
ECOGProt.No.
Item
ECOG Prot. No.
text
ECOGPatientSeq.No.
Item
ECOG Patient Seq. No.
text
ParticipatingGroupProt.No.
Item
Participating Group Prot. No.
text
ParticipatingGroupPatientIDNo.
Item
Participating Group Patient ID No.
text
Group
Item
Group
text
Institution
Item
Institution
text
StepNo.
Item
Step No.
text
AffiliateName
Item
Affiliate (COMPLETE FOR SLIDES)
text
Item Group
Part B
Item
STATUS (See Below)
text
CL.2
Code List
STATUS (See Below)
CL Item
Original Diagnostic Material (Original Diagnostic Material)
CL Item
Pre-protocol Treatment Biopsy (Pre-Protocol Treatment Biopsy)
CL Item
Post-protocol Treatment Biopsy (Post-Protocol Treatment Biopsy)
CL Item
Post-surgery Biopsy (Post-Surgery Biopsy)
CL Item
Relapse/recurrence (Relapse/Recurrence)
CL Item
Remission/response (Remission/Response)
CL Item
Other, Specify (Other, Specify)
Item
STATUS (See Below)
text
CL.2
Code List
STATUS (See Below)
CL Item
Original Diagnostic Material (Original Diagnostic Material)
CL Item
Pre-protocol Treatment Biopsy (Pre-Protocol Treatment Biopsy)
CL Item
Post-protocol Treatment Biopsy (Post-Protocol Treatment Biopsy)
CL Item
Post-surgery Biopsy (Post-Surgery Biopsy)
CL Item
Relapse/recurrence (Relapse/Recurrence)
CL Item
Remission/response (Remission/Response)
CL Item
Other, Specify (Other, Specify)
Other,Specify(specimenstatus)
Item
Other, Specify (specimen status)
text
Other,Specify(specimenstatus)
Item
Other, Specify (specimen status)
text
DATESPECIMENCOLLECTED
Item
DATE SPECIMEN COLLECTED (M,D,Y)
date
DATESPECIMENCOLLECTED
Item
DATE SPECIMEN COLLECTED (M,D,Y)
date
TelephoneNo.
Item
Telephone No.
double
DISEASESITE
Item
DISEASE SITE
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
DISEASESITE
Item
DISEASE SITE
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
NUMBEROFSLIDES
Item
NUMBER OF SLIDES
text
TYPEOFSTAIN
Item
TYPE OF STAIN
text
SPECIMENIDNUMBERS
Item
SPECIMEN ID NUMBERS
text
SPECIMENIDNUMBERS
Item
SPECIMEN ID NUMBERS
text
NUMBEROFBLOCKS
Item
NUMBER OF BLOCKS
text
TYPEOFFIXATIVE
Item
TYPE OF FIXATIVE
text
SubmittingPathologist
Item
Submitting Pathologist
text
Address
Item
Address
text
INSTITUTIONCOMMENTS
Item
INSTITUTION COMMENTS
text
Item
Can this sample be retained by the ECOG Central Tissue Repository? (NOTE: Samples submitted for protocols requiring submission for tissue banking will not be returned except for purposes of individual patient management. For this reason, the submitting pathologist should retain at least one paraffin block at their institution. )
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.3
Code List
Can this sample be retained by the ECOG Central Tissue Repository? (NOTE: Samples submitted for protocols requiring submission for tissue banking will not be returned except for purposes of individual patient management. For this reason, the submitting pathologist should retain at least one paraffin block at their institution. )
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
A block has been retained at the submitting institution
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
A block has been retained at the submitting institution
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Please CIRCLE THE REASON for non-submission (and INCLUDE a formal letter of explanation)
text
CL.5
Code List
Please CIRCLE THE REASON for non-submission (and INCLUDE a formal letter of explanation)
CL Item
State Regulations (State Regulations)
CL Item
Institutional Policy (Institutional Policy)
C0079630 (NCI Metathesaurus)
CL Item
Insufficient Tissue (Insufficient Tissue)
CL Item
Patient Refusal (Patient Refusal)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
specifyother(reasonfornon-submission)
Item
specify other (reason for non-submission)
text
PathologistorInvestigator'sSignature
Item
Pathologist or Investigator's Signature
text
Item Group
Part C
DateSampleReceivedbyECOG
Item
Date Sample Received by ECOG (M D Y )
date
DateSenttoCentralLab
Item
Date Sent to Central Lab (M D Y )
date
DateSampleSenttoReviewer
Item
Date Sample Sent to Reviewer (M D Y )
date
ItemsReceived
Item
Items Received (if different from above)
text
NameofReviewer
Item
Name of Reviewer
text
Notes
Item
NOTES
text
Item Group
Ccrr Module For Ecog Pathology Material Submission Form (e2100)
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