ID

10283

Beskrivning

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

Länk

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

Nyckelord

  1. 2012-08-27 2012-08-27 -
  2. 2015-05-22 2015-05-22 -
Uppladdad den

22 maj 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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ECOG PATHOLOGY MATERIAL SUBMISSION FORM (E2100)

Form No. 638

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

Part A

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

DateSampleSenttoECOG

Datatyp

date

Data Manager
Beskrivning

DataManager

Datatyp

text

Telephone No.
Beskrivning

TelephoneNo.

Datatyp

double

FAX No.
Beskrivning

FAXNo.

Datatyp

double

ECOG Parent Prot. No.
Beskrivning

ECOGParentProt.No.

Datatyp

text

Seq. No.
Beskrivning

Seq.No.

Datatyp

text

Patient's Name
Beskrivning

Patient'sName

Datatyp

text

ECOG Prot. No.
Beskrivning

ECOGProt.No.

Datatyp

text

ECOG Patient Seq. No.
Beskrivning

ECOGPatientSeq.No.

Datatyp

text

Participating Group Prot. No.
Beskrivning

ParticipatingGroupProt.No.

Datatyp

text

Participating Group Patient ID No.
Beskrivning

ParticipatingGroupPatientIDNo.

Datatyp

text

Group
Beskrivning

Group

Datatyp

text

Institution
Beskrivning

Institution

Datatyp

text

Step No.
Beskrivning

StepNo.

Datatyp

text

Affiliate (COMPLETE FOR SLIDES)
Beskrivning

AffiliateName

Datatyp

text

Part B
Beskrivning

Part B

STATUS (See Below)
Beskrivning

STATUS

Datatyp

text

STATUS (See Below)
Beskrivning

STATUS

Datatyp

text

Other, Specify (specimen status)
Beskrivning

Other,Specify(specimenstatus)

Datatyp

text

Other, Specify (specimen status)
Beskrivning

Other,Specify(specimenstatus)

Datatyp

text

DATE SPECIMEN COLLECTED (M,D,Y)
Beskrivning

DATESPECIMENCOLLECTED

Datatyp

date

DATE SPECIMEN COLLECTED (M,D,Y)
Beskrivning

DATESPECIMENCOLLECTED

Datatyp

date

Telephone No.
Beskrivning

TelephoneNo.

Datatyp

double

DISEASE SITE
Beskrivning

DISEASESITE

Datatyp

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
Beskrivning

DISEASESITE

Datatyp

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
Beskrivning

NUMBEROFSLIDES

Datatyp

text

TYPE OF STAIN
Beskrivning

TYPEOFSTAIN

Datatyp

text

SPECIMEN ID NUMBERS
Beskrivning

SPECIMENIDNUMBERS

Datatyp

text

SPECIMEN ID NUMBERS
Beskrivning

SPECIMENIDNUMBERS

Datatyp

text

NUMBER OF BLOCKS
Beskrivning

NUMBEROFBLOCKS

Datatyp

text

TYPE OF FIXATIVE
Beskrivning

TYPEOFFIXATIVE

Datatyp

text

Submitting Pathologist
Beskrivning

SubmittingPathologist

Datatyp

text

Address
Beskrivning

Address

Datatyp

text

INSTITUTION COMMENTS
Beskrivning

INSTITUTIONCOMMENTS

Datatyp

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. )
Beskrivning

CanthissampleberetainedbytheECOGCentralTissueRepository?

Datatyp

text

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

Ablockhasbeenretainedatthesubmittinginstitution

Datatyp

text

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

PleaseCIRCLETHEREASONfornon-submission

Datatyp

text

specify other (reason for non-submission)
Beskrivning

specifyother(reasonfornon-submission)

Datatyp

text

Pathologist or Investigator's Signature
Beskrivning

PathologistorInvestigator'sSignature

Datatyp

text

Part C
Beskrivning

Part C

Date Sample Received by ECOG (M D Y )
Beskrivning

DateSampleReceivedbyECOG

Datatyp

date

Date Sent to Central Lab (M D Y )
Beskrivning

DateSenttoCentralLab

Datatyp

date

Date Sample Sent to Reviewer (M D Y )
Beskrivning

DateSampleSenttoReviewer

Datatyp

date

Items Received (if different from above)
Beskrivning

ItemsReceived

Datatyp

text

Name of Reviewer
Beskrivning

NameofReviewer

Datatyp

text

NOTES
Beskrivning

Notes

Datatyp

text

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

Ccrr Module For Ecog Pathology Material Submission Form (e2100)

Similar models

Form No. 638

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