ID

10495

Description

Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Pathology Submission Form NCT00033631 Radiation Therapy in Treating Patients With Stage II Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CF5748-0C1F-4085-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CF5748-0C1F-4085-E044-0003BA3F9857

Mots-clés

Versions (4)
  1. 19/09/2012 19/09/2012 -
  2. 08/08/2014 08/08/2014 - Martin Dugas
  3. 02/06/2015 02/06/2015 -
  4. 03/06/2015 03/06/2015 -
Téléchargé le

3 juin 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Pathology Submission Form NCT00033631

Anglais

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 Formulaires  
RTOG clinical trial administrative data
Description

RTOG clinical trial administrative data

RTOG Study
Description

RTOGStudy

Type de données

text

Case #
Description

Case#

Type de données

text

Institution
Description

Institution

Type de données

text

Institution No.
Description

InstitutionNo.

Type de données

text

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

Patient'sName

Type de données

text

Patient's I.D. No.
Description

Patient'sI.D.No.

Type de données

text

Instructions
Description

Instructions

Pathology submission
Description

Pathology submission

TYPE (pathology submission)
Description

TYPE(pathologysubmission)

Type de données

text

PROCEDURE DATE
Description

Procedure Date

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS
C2584899
SITE OF MATERIAL
Description

SITEOFMATERIAL

Type de données

text

H&E Stained Slides (NUMBER OF SPECIMENS)
Description

H&EStainedSlides

Type de données

float

Unstained Slides (NUMBER OF SPECIMENS)
Description

UnstainedSlides

Type de données

float

Blocks (NUMBER OF SPECIMENS)
Description

Blocks

Type de données

float

PATHOLOGY ACCESSION #
Description

PATHOLOGYACCESSION#

Type de données

text

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

RTOGCalendarduedate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
REQUIRED ENCLOSURES
Description

REQUIREDENCLOSURES

Type de données

text

Patient consents to: (Check all that apply and submit with patient study consent form.)
Description

Patientconsentsto:

Type de données

text

SUBMITTED BY
Description

PersonSpecimenSubmittedName

Type de données

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

Type de données

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 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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
Instructions
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
text
H&EStainedSlides
Item
H&E Stained Slides (NUMBER OF SPECIMENS)
float
UnstainedSlides
Item
Unstained Slides (NUMBER OF SPECIMENS)
float
Blocks
Item
Blocks (NUMBER OF SPECIMENS)
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
text
CL.2
Code List
REQUIRED ENCLOSURES
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: (Check all that apply and submit with patient study consent form.)
text
CL.3
Code List
Patient consents to: (Check all that apply and submit with patient study consent form.)
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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