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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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- 27-08-12 27-08-12 -
- 22-05-15 22-05-15 -
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ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
Form No. 638
- StudyEvent: ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
Similar models
Form No. 638
- StudyEvent: ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
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
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)
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)
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)
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)
C1522602 (UMLS 2011AA ValueDomain)
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)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
A block has been retained at the submitting institution
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
Item
Please CIRCLE THE REASON for non-submission (and INCLUDE a formal letter of explanation)
text
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)
C0205394 (UMLS 2011AA)
specifyother(reasonfornon-submission)
Item
specify other (reason for non-submission)
text
PathologistorInvestigator'sSignature
Item
Pathologist or Investigator's Signature
text
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