ID

10283

Beschreibung

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

Link

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

Stichworte

Versionen (2)
  1. 27.08.12 27.08.12 -
  2. 22.05.15 22.05.15 -
Hochgeladen am

22. Mai 2015

DOI

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ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)

Englisch

Form No. 638

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

Part A

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

DateSampleSenttoECOG

Datentyp

date

Data Manager
Beschreibung

DataManager

Datentyp

text

Telephone No.
Beschreibung

TelephoneNo.

Datentyp

double

FAX No.
Beschreibung

FAXNo.

Datentyp

double

ECOG Parent Prot. No.
Beschreibung

ECOGParentProt.No.

Datentyp

text

Seq. No.
Beschreibung

Seq.No.

Datentyp

text

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

ECOG Prot. No.
Beschreibung

ECOGProt.No.

Datentyp

text

ECOG Patient Seq. No.
Beschreibung

ECOGPatientSeq.No.

Datentyp

text

Participating Group Prot. No.
Beschreibung

ParticipatingGroupProt.No.

Datentyp

text

Participating Group Patient ID No.
Beschreibung

ParticipatingGroupPatientIDNo.

Datentyp

text

Group
Beschreibung

Group

Datentyp

text

Institution
Beschreibung

Institution

Datentyp

text

Step No.
Beschreibung

StepNo.

Datentyp

text

Affiliate (COMPLETE FOR SLIDES)
Beschreibung

AffiliateName

Datentyp

text

Part B
Beschreibung

Part B

STATUS (See Below)
Beschreibung

STATUS

Datentyp

text

STATUS (See Below)
Beschreibung

STATUS

Datentyp

text

Other, Specify (specimen status)
Beschreibung

Other,Specify(specimenstatus)

Datentyp

text

Other, Specify (specimen status)
Beschreibung

Other,Specify(specimenstatus)

Datentyp

text

DATE SPECIMEN COLLECTED (M,D,Y)
Beschreibung

DATESPECIMENCOLLECTED

Datentyp

date

DATE SPECIMEN COLLECTED (M,D,Y)
Beschreibung

DATESPECIMENCOLLECTED

Datentyp

date

Telephone No.
Beschreibung

TelephoneNo.

Datentyp

double

DISEASE SITE
Beschreibung

DISEASESITE

Datentyp

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
Beschreibung

DISEASESITE

Datentyp

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
Beschreibung

NUMBEROFSLIDES

Datentyp

text

TYPE OF STAIN
Beschreibung

TYPEOFSTAIN

Datentyp

text

SPECIMEN ID NUMBERS
Beschreibung

SPECIMENIDNUMBERS

Datentyp

text

SPECIMEN ID NUMBERS
Beschreibung

SPECIMENIDNUMBERS

Datentyp

text

NUMBER OF BLOCKS
Beschreibung

NUMBEROFBLOCKS

Datentyp

text

TYPE OF FIXATIVE
Beschreibung

TYPEOFFIXATIVE

Datentyp

text

Submitting Pathologist
Beschreibung

SubmittingPathologist

Datentyp

text

Address
Beschreibung

Address

Datentyp

text

INSTITUTION COMMENTS
Beschreibung

INSTITUTIONCOMMENTS

Datentyp

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. )
Beschreibung

CanthissampleberetainedbytheECOGCentralTissueRepository?

Datentyp

text

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

Ablockhasbeenretainedatthesubmittinginstitution

Datentyp

text

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

PleaseCIRCLETHEREASONfornon-submission

Datentyp

text

specify other (reason for non-submission)
Beschreibung

specifyother(reasonfornon-submission)

Datentyp

text

Pathologist or Investigator's Signature
Beschreibung

PathologistorInvestigator'sSignature

Datentyp

text

Part C
Beschreibung

Part C

Date Sample Received by ECOG (M D Y )
Beschreibung

DateSampleReceivedbyECOG

Datentyp

date

Date Sent to Central Lab (M D Y )
Beschreibung

DateSenttoCentralLab

Datentyp

date

Date Sample Sent to Reviewer (M D Y )
Beschreibung

DateSampleSenttoReviewer

Datentyp

date

Items Received (if different from above)
Beschreibung

ItemsReceived

Datentyp

text

Name of Reviewer
Beschreibung

NameofReviewer

Datentyp

text

NOTES
Beschreibung

Notes

Datentyp

text

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

Ccrr Module For Ecog Pathology Material Submission Form (e2100)

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Ähnliche Modelle

Form No. 638

1 Formulare
  1. StudyEvent: ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
    1. Form No. 638
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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