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ID

10483

Beschrijving

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

Trefwoorden

  1. 18-12-14 18-12-14 - Martin Dugas
  2. 02-06-15 02-06-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

3 juni 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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    CALGB: 80101 BLOOD SAMPLE TRACKING FORM NCT00052910

    No Instruction available.

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

    CALGB clinical trial administrative data

    CALGB Form
    Beschrijving

    CALGBForm

    Datatype

    text

    CALGB Study No
    Beschrijving

    CALGBProtocolNumber

    Datatype

    text

    CALGB Patient ID
    Beschrijving

    CALGBPatientID

    Datatype

    text

    Patient's Name
    Beschrijving

    PatientName,Last

    Datatype

    text

    Participating Group
    Beschrijving

    ParticipatingGroupCode

    Datatype

    text

    Patient Hospital Number
    Beschrijving

    PatientMedicalRecordNumber

    Datatype

    text

    Participating Group Protocol No.
    Beschrijving

    Particip.GroupProtocolNumber

    Datatype

    float

    Main Member Institution/Adjunct
    Beschrijving

    InstitutionName

    Datatype

    text

    Participating Group Patient No.
    Beschrijving

    PatientStudyID,ParticipatingGroup

    Datatype

    text

    Date form submitted
    Beschrijving

    Dateformsubmitted

    Datatype

    text

    Amended data?
    Beschrijving

    AmendedDataInd

    Datatype

    text

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

    To Be Completed By Submitting Institution

    Does specimen accompany this form?
    Beschrijving

    Specimenw/FormInd

    Datatype

    text

    Specify reason
    Beschrijving

    Specifyreason

    Datatype

    text

    Date sample collected
    Beschrijving

    SpecimenCollectionDate

    Datatype

    date

    Number of tubes of whole blood submitted with this form
    Beschrijving

    WholeBloodTubesSubmittedCount

    Datatype

    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
    Beschrijving

    SpecimenCollectionTime

    Datatype

    text

    Submitted by
    Beschrijving

    PersonSpecimenSubmittedName

    Datatype

    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 #
    Beschrijving

    PhoneNumber

    Datatype

    float

    To Be Completed By Receiving Institution/laboratory
    Beschrijving

    To Be Completed By Receiving Institution/laboratory

    Date sample received
    Beschrijving

    SpecimenReceivedDate

    Datatype

    date

    Sample condition
    Beschrijving

    Samplecondition

    Datatype

    text

    Sample ID no.
    Beschrijving

    SpecimenID

    Datatype

    float

    Received by
    Beschrijving

    PersonSpecimenReceivedName

    Datatype

    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?
    Beschrijving

    SpecimenEvaluableInd

    Datatype

    text

    Similar models

    No Instruction available.

    1. StudyEvent: CALGB: 80101 BLOOD SAMPLE TRACKING FORM
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    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)
    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
    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
    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
    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
    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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