ID

10634

Descrição

CALGB: SPECIMEN ROUTING FORM WHOLE BLOOD NCT00016276 Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-824D-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-824D-227A-E034-080020C9C0E0

Palavras-chave

  1. 26/08/2012 26/08/2012 -
  2. 22/05/2015 22/05/2015 -
  3. 03/06/2015 03/06/2015 -
  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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CALGB: SPECIMEN ROUTING FORM WHOLE BLOOD NCT00016276

No Instruction available.

  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM WHOLE BLOOD
    1. No Instruction available.
CALGB clinical trial administrative data
Descrição

CALGB clinical trial administrative data

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBProtocolNumber

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Amended data?
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient demographics
Descrição

Patient demographics

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

Patient Hospital Number
Descrição

PatientHospitalNumber

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Main Member Institution/Adjunct
Descrição

MainMemberInstitution/Adjunct

Tipo de dados

text

Participating Group Patient No.
Descrição

ParticipatingGroupPatientNo.

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroup

Tipo de dados

text

To Be Completed By Submitting Institution
Descrição

To Be Completed By Submitting Institution

Blood Sample (plasma)
Descrição

BloodSample

Tipo de dados

text

Date plasma specimen collected
Descrição

Dateplasmaspecimencollected

Tipo de dados

text

CALGB Treatment Study
Descrição

CALGBTreatmentStudy

Tipo de dados

text

Does specimen accompany this form? (If yes, complete the remainder of this form.)
Descrição

Specimenw/FormInd

Tipo de dados

text

Number of tubes submitted
Descrição

Numberoftubessubmitted

Tipo de dados

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C41277
UMLS 2011AA ObjectClass
C1561954
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Date sample sent
Descrição

Datesamplesent

Tipo de dados

text

Specimen Collected (mark one with an X)
Descrição

SpecimenCollected

Tipo de dados

text

Alias
NCI Thesaurus Property
C25453
UMLS 2011AA Property
C1516698
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
Responsible treating physician
Descrição

Responsibletreatingphysician:

Tipo de dados

text

Phone Number to be used in event of sample problems
Descrição

PhoneNumbertobeusedineventofsampleproblems:

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C40978
UMLS 2011AA Property
C1515258
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
If no, specify reason
Descrição

Ifno,specifyreason

Tipo de dados

text

Completed By
Descrição

CompletedBy

Tipo de dados

text

Date Completed
Descrição

DateCompleted

Tipo de dados

text

To Be Completed By Receiving Institution/laboratory
Descrição

To Be Completed By Receiving Institution/laboratory

Date sample received
Descrição

Datesamplereceived

Tipo de dados

text

Sample Condition (mark one with an X)
Descrição

SampleCondition

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C12801
UMLS 2011AA ObjectClass
C0040300
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C25457
UMLS 2011AA Property
C0348080
Sample ID no.
Descrição

SpecimenID

Tipo de dados

double

Number of Aliquots
Descrição

NumberofAliquots

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
Average aliquot volume (cc)
Descrição

Averagealiquotvolume

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25335
UMLS 2011AA Property
C0449468
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain
C37917
UMLS 2011AA ValueDomain
C1510992
Sample received by
Descrição

Samplereceivedby

Tipo de dados

text

Similar models

No Instruction available.

  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM WHOLE BLOOD
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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
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
Patient demographics
Patient'sName
Item
Patient's Name
text
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
ParticipatingGroup
Item
Participating Group
text
Item Group
To Be Completed By Submitting Institution
BloodSample
Item
Blood Sample (plasma)
text
Dateplasmaspecimencollected
Item
Date plasma specimen collected
text
CALGBTreatmentStudy
Item
CALGB Treatment Study
text
Item
Does specimen accompany this form? (If yes, complete the remainder of this form.)
text
Code List
Does specimen accompany this form? (If yes, complete the remainder of this form.)
CL Item
No (No)
CL Item
Yes (Yes)
Numberoftubessubmitted
Item
Number of tubes submitted
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C41277 (NCI Thesaurus ObjectClass)
C1561954 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
Datesamplesent
Item
Date sample sent
text
Item
Specimen Collected (mark one with an X)
text
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
Code List
Specimen Collected (mark one with an X)
CL Item
Pre-treatment (Pre-treatment)
CL Item
During Initial Treatment (During Initial Treatment)
CL Item
During Follow-up, No. Therapy (During Follow-Up, No. Therapy)
CL Item
At Relapse/progression (At Relapse/Progression)
Responsibletreatingphysician:
Item
Responsible treating physician
text
PhoneNumbertobeusedineventofsampleproblems:
Item
Phone Number to be used in event of sample problems
text
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C40978 (NCI Thesaurus Property)
C1515258 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Ifno,specifyreason
Item
If no, specify reason
text
CompletedBy
Item
Completed By
text
DateCompleted
Item
Date Completed
text
Item Group
To Be Completed By Receiving Institution/laboratory
Datesamplereceived
Item
Date sample received
text
Item
Sample Condition (mark one with an X)
text
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25457 (NCI Thesaurus Property)
C0348080 (UMLS 2011AA Property)
Code List
Sample Condition (mark one with an X)
CL Item
Okay (Okay)
CL Item
Damaged (Damaged)
CL Item
Missing (Missing)
C54031 (NCI Thesaurus)
C1705492 (UMLS 2011AA)
CL Item
Insufficient Amount (Insufficient amount)
CL Item
Damaged But Stored (Damaged but stored)
CL Item
Thawed But Stored (Thawed but stored)
CL Item
Improperly Stored (Improperly stored)
SpecimenID
Item
Sample ID no.
double
NumberofAliquots
Item
Number of Aliquots
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
Averagealiquotvolume
Item
Average aliquot volume (cc)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25335 (NCI Thesaurus Property)
C0449468 (UMLS 2011AA Property)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C37917 (NCI Thesaurus ValueDomain)
C1510992 (UMLS 2011AA ValueDomain)
Samplereceivedby
Item
Sample received by
text

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