ID

10495

Descrição

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

Link

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

Palavras-chave

Versões (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 -
Transferido a

3 de junho de 2015

DOI

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Licença

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

Inglês

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 Formulários  
RTOG clinical trial administrative data
Descrição

RTOG clinical trial administrative data

RTOG Study
Descrição

RTOGStudy

Tipo de dados

text

Case #
Descrição

Case#

Tipo de dados

text

Institution
Descrição

Institution

Tipo de dados

text

Institution No.
Descrição

InstitutionNo.

Tipo de dados

text

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

Patient'sName

Tipo de dados

text

Patient's I.D. No.
Descrição

Patient'sI.D.No.

Tipo de dados

text

Instructions
Descrição

Instructions

Pathology submission
Descrição

Pathology submission

TYPE (pathology submission)
Descrição

TYPE(pathologysubmission)

Tipo de dados

text

PROCEDURE DATE
Descrição

Procedure Date

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS
C2584899
SITE OF MATERIAL
Descrição

SITEOFMATERIAL

Tipo de dados

text

H&E Stained Slides (NUMBER OF SPECIMENS)
Descrição

H&EStainedSlides

Tipo de dados

float

Unstained Slides (NUMBER OF SPECIMENS)
Descrição

UnstainedSlides

Tipo de dados

float

Blocks (NUMBER OF SPECIMENS)
Descrição

Blocks

Tipo de dados

float

PATHOLOGY ACCESSION #
Descrição

PATHOLOGYACCESSION#

Tipo de dados

text

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

RTOGCalendarduedate

Tipo de dados

date

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

REQUIREDENCLOSURES

Tipo de dados

text

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

Patientconsentsto:

Tipo de dados

text

SUBMITTED BY
Descrição

PersonSpecimenSubmittedName

Tipo de dados

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
Descrição

TELEPHONENO

Tipo de dados

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
Descrição

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 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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