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10494

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Radiation Therapy Oncology Group Pathology Submission Form NCT00023829 Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CFF7E-9D16-2C2B-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CFF7E-9D16-2C2B-E034-080020C9C0E0

Keywords

Versions (4)
  1. 9/19/12 9/19/12 -
  2. 8/8/14 8/8/14 - Martin Dugas
  3. 6/2/15 6/2/15 -
  4. 6/3/15 6/3/15 -
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June 3, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Radiation Therapy Oncology Group Pathology Submission Form NCT00023829

    English

    INSTRUCTIONS This form must be completed and mailed with the pathology specimens whenever slides or blocks are sent to LDS Hospital. Please see protocol for list of required materials.

    1 forms  
    RTOG clinical trial administrative data
    Description

    RTOG clinical trial administrative data

    RTOG Study
    Description

    RTOGStudy

    Data type

    text

    Case #
    Description

    Case#

    Data type

    text

    Institution
    Description

    Institution

    Data type

    text

    Institution No.
    Description

    InstitutionNo.

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Patient's Name
    Description

    Patient'sName

    Data type

    text

    Patient's I.D. No.
    Description

    Patient'sI.D.No.

    Data type

    text

    Pathology submission
    Description

    Pathology submission

    TYPE (pathology submission)
    Description

    TYPE(pathologysubmission)

    Data type

    text

    PROCEDURE DATE
    Description

    Procedure Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS
    C2584899
    SITE OF MATERIAL (NUMBER OF SPECIMENS)
    Description

    SITEOFMATERIAL

    Data type

    text

    H&E Stained Slides
    Description

    H&EStainedSlides

    Data type

    float

    Unstained Slides
    Description

    UnstainedSlides

    Data type

    float

    Blocks
    Description

    Blocks

    Data type

    float

    PATHOLOGY ACCESSION #
    Description

    PATHOLOGYACCESSION#

    Data type

    text

    RTOG Calendar due date ("P1, P2")
    Description

    RTOGCalendarduedate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
    Description

    REQUIREDENCLOSURES

    Data type

    text

    Patient consents to:
    Description

    Patientconsentsto:

    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
    TELEPHONE NO
    Description

    TELEPHONENO

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ValueDomain-2
    C25395
    UMLS 2011AA ValueDomain-2
    C0039457
    Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form
    Description

    Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form

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    Similar models

    INSTRUCTIONS This form must be completed and mailed with the pathology specimens whenever slides or blocks are sent to LDS Hospital. Please see protocol for list of required materials.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    RTOG clinical trial administrative data
    RTOGStudy
    Item
    RTOG Study
    text
    Case#
    Item
    Case #
    text
    Institution
    Item
    Institution
    text
    InstitutionNo.
    Item
    Institution No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    Patient'sName
    Item
    Patient's Name
    text
    Patient'sI.D.No.
    Item
    Patient's I.D. No.
    text
    Item Group
    Pathology submission
    Item
    TYPE (pathology submission)
    text
    CL.1
    Code List
    TYPE (pathology submission)
    CL Item
    Pre-treatment Bx (Pre-treatment Bx)
    CL Item
    Surgical Treatment (Surgical treatment)
    CL Item
    Post-treatment Bx (Post-treatment Bx)
    CL Item
    Autopsy (Autopsy)
    C25153 (NCI Thesaurus)
    C0004398 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    Procedure Date
    Item
    PROCEDURE DATE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2584899 (UMLS)
    SITEOFMATERIAL
    Item
    SITE OF MATERIAL (NUMBER OF SPECIMENS)
    text
    H&EStainedSlides
    Item
    H&E Stained Slides
    float
    UnstainedSlides
    Item
    Unstained Slides
    float
    Blocks
    Item
    Blocks
    float
    PATHOLOGYACCESSION#
    Item
    PATHOLOGY ACCESSION #
    text
    RTOGCalendarduedate
    Item
    RTOG Calendar due date ("P1, P2")
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
    text
    CL.2
    Code List
    REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
    CL Item
    Pathology Report(s) (Pathology Report(s))
    CL Item
    Blocks/slides (Blocks/Slides)
    CL Item
    This Submission Form (This Submission Form)
    CL Item
    Patient Consent (Patient consent)
    Item
    Patient consents to:
    text
    CL.3
    Code List
    Patient consents to:
    CL Item
    Current Research As Specified In The Protocol (Current research as specified in the protocol)
    CL Item
    Future Research Using Tissue Bank Samples (Future research using Tissue Bank samples)
    CL Item
    Being Contacted About Future Research (Being contacted about future research)
    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)
    TELEPHONENO
    Item
    TELEPHONE NO
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25395 (NCI Thesaurus ValueDomain-2)
    C0039457 (UMLS 2011AA ValueDomain-2)
    Item Group
    Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form
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