ID

10483

Description

CALGB: 80101 BLOOD SAMPLE TRACKING FORM Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-FA7B-5976-E034-080020C9C0E0 NCT00052910

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-FA7B-5976-E034-080020C9C0E0

Keywords

Versions (3)
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 6/2/15 6/2/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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CALGB: 80101 BLOOD SAMPLE TRACKING FORM NCT00052910

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB: 80101 BLOOD SAMPLE TRACKING FORM
    1. No Instruction available.
CALGB clinical trial administrative data
Description

CALGB clinical trial administrative data

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBProtocolNumber

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Patient's Name
Description

PatientName,Last

Data type

text

Participating Group
Description

ParticipatingGroupCode

Data type

text

Patient Hospital Number
Description

PatientMedicalRecordNumber

Data type

text

Participating Group Protocol No.
Description

Particip.GroupProtocolNumber

Data type

float

Main Member Institution/Adjunct
Description

InstitutionName

Data type

text

Participating Group Patient No.
Description

PatientStudyID,ParticipatingGroup

Data type

text

Date form submitted
Description

Dateformsubmitted

Data type

text

Amended data?
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
To Be Completed By Submitting Institution
Description

To Be Completed By Submitting Institution

Does specimen accompany this form?
Description

Specimenw/FormInd

Data type

text

Specify reason
Description

Specifyreason

Data type

text

Date sample collected
Description

SpecimenCollectionDate

Data type

date

Number of tubes of whole blood submitted with this form
Description

WholeBloodTubesSubmittedCount

Data type

float

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C41067
UMLS 2011AA ObjectClass
C1608383
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Metathesaurus Property
C0175730
Sample time Point
Description

SpecimenCollectionTime

Data type

text

Submitted by
Description

PersonSpecimenSubmittedName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property-2
C25695
UMLS 2011AA Property-2
C1515023
Phone #
Description

PhoneNumber

Data type

float

To Be Completed By Receiving Institution/laboratory
Description

To Be Completed By Receiving Institution/laboratory

Date sample received
Description

SpecimenReceivedDate

Data type

date

Sample condition
Description

Samplecondition

Data type

text

Sample ID no.
Description

SpecimenID

Data type

float

Received by
Description

PersonSpecimenReceivedName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property-2
C19157
UMLS 2011AA Property-2
C0370003
Is sample evaluable for analysis?
Description

SpecimenEvaluableInd

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB: 80101 BLOOD SAMPLE TRACKING FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
float
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Dateformsubmitted
Item
Date form submitted
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
To Be Completed By Submitting Institution
Item
Does specimen accompany this form?
text
CL.2
Code List
Does specimen accompany this form?
CL Item
No, Specify Reason (No, specify reason)
CL Item
Yes, Complete The Remainder Of Form (Yes, complete the remainder of form)
Specifyreason
Item
Specify reason
text
SpecimenCollectionDate
Item
Date sample collected
date
WholeBloodTubesSubmittedCount
Item
Number of tubes of whole blood submitted with this form
float
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C41067 (NCI Thesaurus ObjectClass)
C1608383 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C0175730 (NCI Metathesaurus Property)
Item
Sample time Point
text
CL.3
Code List
Sample time Point
CL Item
1-pre-study (1-pre-study)
PersonSpecimenSubmittedName
Item
Submitted by
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property-2)
C1515023 (UMLS 2011AA Property-2)
PhoneNumber
Item
Phone #
float
Item Group
To Be Completed By Receiving Institution/laboratory
SpecimenReceivedDate
Item
Date sample received
date
Item
Sample condition
text
CL.4
Code List
Sample condition
CL Item
Okay (Okay)
CL Item
Damaged (Damaged)
CL Item
Missing (Missing)
CL Item
Thawed (Thawed)
CL Item
Insufficient Amount (Insufficient amount)
CL Item
Clotted (Clotted)
SpecimenID
Item
Sample ID no.
float
PersonSpecimenReceivedName
Item
Received by
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property-2)
C0370003 (UMLS 2011AA Property-2)
Item
Is sample evaluable for analysis?
text
CL.5
Code List
Is sample evaluable for analysis?
CL Item
No, Procedural Deviations Definitely Affect Analysis (No, procedural deviations definitely affect analysis)
CL Item
Yes, Sample Is Evaluable (Yes, sample is evaluable)
CL Item
Unsure, Procedural Deviations May Affect Analysis (Unsure, procedural deviations may affect analysis)
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