ID

10494

Beschrijving

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

Trefwoorden

Versies (4)
  1. 19-09-12 19-09-12 -
  2. 08-08-14 08-08-14 - Martin Dugas
  3. 02-06-15 02-06-15 -
  4. 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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Radiation Therapy Oncology Group Pathology Submission Form NCT00023829

Engels

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 Formulieren  
RTOG clinical trial administrative data
Beschrijving

RTOG clinical trial administrative data

RTOG Study
Beschrijving

RTOGStudy

Datatype

text

Case #
Beschrijving

Case#

Datatype

text

Institution
Beschrijving

Institution

Datatype

text

Institution No.
Beschrijving

InstitutionNo.

Datatype

text

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

Patient'sName

Datatype

text

Patient's I.D. No.
Beschrijving

Patient'sI.D.No.

Datatype

text

Pathology submission
Beschrijving

Pathology submission

TYPE (pathology submission)
Beschrijving

TYPE(pathologysubmission)

Datatype

text

PROCEDURE DATE
Beschrijving

Procedure Date

Datatype

date

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

SITEOFMATERIAL

Datatype

text

H&E Stained Slides
Beschrijving

H&EStainedSlides

Datatype

float

Unstained Slides
Beschrijving

UnstainedSlides

Datatype

float

Blocks
Beschrijving

Blocks

Datatype

float

PATHOLOGY ACCESSION #
Beschrijving

PATHOLOGYACCESSION#

Datatype

text

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

RTOGCalendarduedate

Datatype

date

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

REQUIREDENCLOSURES

Datatype

text

Patient consents to:
Beschrijving

Patientconsentsto:

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
TELEPHONE NO
Beschrijving

TELEPHONENO

Datatype

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
Beschrijving

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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