ID
11096
Description
The Pharmacogenomic Submission and Quality Assurance Form, a CDE-compliant CALGB CRF to be used on CALGB protocols. NCT00770809 Paclitaxel and Trastuzumab With or Without Lapatinib in Treating Patients With Stage II or Stage III Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3CB305DE-32D4-5C21-E044-0003BA3F9857
Link
Keywords
Versions (3)
- 8/27/12 8/27/12 -
- 1/9/15 1/9/15 - Martin Dugas
- 6/18/15 6/18/15 -
Uploaded on
June 18, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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CALGB: Pharmacogenomic Submission and Quality Assurance Form NCT00770809
For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box.
- StudyEvent: CALGB: Pharmacogenomic Submission and Quality Assurance Form
Description
Patient demographics
Description
Patient Initials
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2986440
- NCI Thesaurus ObjectClass
- C16960
- NCI Thesaurus Property
- C25536
Description
Patient Hospital No
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C0421459
- NCI Thesaurus Property
- C16960
- NCI Thesaurus Property-2
- C25364
- NCI Thesaurus ObjectClass
- C16696
Description
Institution Name
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS CUI-1
- C1301943
- NCI Thesaurus ObjectClass-2
- C21541
- NCI Thesaurus Property
- C25364
- NCI Thesaurus ValueDomain
- C25191
- NCI Thesaurus ValueDomain-2
- C21541
Description
Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS CUI-1
- C2347449
- NCI Thesaurus ObjectClass
- C25608
- NCI Thesaurus ObjectClass-2
- C17005
- NCI Thesaurus Property
- C25364
Description
Study Number Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C3274381
- NCI Thesaurus ObjectClass
- C25320
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Trial subject ID Participating Group
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS CUI-1
- C2348585
- NCI Thesaurus ObjectClass
- C16960
- UMLS CUI-2
- C2347449
- NCI Thesaurus Property
- C25608
- NCI Thesaurus Property-2
- C25364
Description
Biopsy and Cytology Specimens
Description
SpecimenFormSubmittedInd-2
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus Property
- C19464
- UMLS 2011AA Property
- C0376315
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property-2
- C25695
- UMLS 2011AA Property-2
- C1515023
Description
SpecimenNotSubmittedReason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus Property
- C25594
- UMLS 2011AA Property
- C1518422
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property-2
- C25695
- UMLS 2011AA Property-2
- C1515023
Description
Biopsy and Cytology Specimens collection
Description
SpecimenCollectedDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property
- C25452
- NCI Thesaurus Property-2
- C25275
- UMLS 2011AA Property
- C2745955
Description
SpecimenCollectedTime
Data type
time
Alias
- NCI Thesaurus ValueDomain
- C25207
- UMLS 2011AA ValueDomain
- C0040223
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property
- C25452
- NCI Thesaurus Property-2
- C25275
- UMLS 2011AA Property
- C2745955
Description
BloodSpecimenTubeCollectedInd-2
Data type
boolean
Alias
- NCI Thesaurus ObjectClass
- C12434
- UMLS 2011AA ObjectClass
- C0229664
- NCI Thesaurus ObjectClass-2
- C19157
- UMLS 2011AA ObjectClass-2
- C0370003
- NCI Thesaurus Property
- C25452
- NCI Thesaurus Property-2
- C41277
- UMLS 2011AA Property
- C1561954
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
BloodSpecimenFrozenCollectedInd-2
Data type
boolean
Alias
- NCI Thesaurus ObjectClass
- C12434
- UMLS 2011AA ObjectClass
- C0229664
- NCI Thesaurus ObjectClass-2
- C19157
- UMLS 2011AA ObjectClass-2
- C0370003
- NCI Metathesaurus Property
- CL267638
- NCI Thesaurus Property
- C25452
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
HematologySpecimenColdPackSubmissionInd-2
Data type
boolean
Alias
- NCI Thesaurus ObjectClass
- C16673
- UMLS 2011AA ObjectClass
- C0018943
- NCI Thesaurus ObjectClass-2
- C19157
- UMLS 2011AA ObjectClass-2
- C0370003
- NCI Thesaurus Property
- C62653
- UMLS 2011AA Property
- C2825051
- NCI Thesaurus Property-2
- C25695
- UMLS 2011AA Property-2
- C1515023
- NCI Thesaurus Property-3
- C62180
- UMLS 2011AA Property-3
- C0009264
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
Biopsy and Cytology Specimens shipment
Description
SpecimenLabSubmittedDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25294
- UMLS 2011AA Property
- C0022885
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property-2
- C25695
- UMLS 2011AA Property-2
- C1515023
Description
SpecimenLaboratoryProcedureSubmissionTime
Data type
time
Alias
- NCI Thesaurus ValueDomain
- C25207
- UMLS 2011AA ValueDomain
- C0040223
- NCI Thesaurus Property
- C25294
- UMLS 2011AA Property
- C0022885
- NCI Thesaurus ObjectClass
- C19157
- UMLS 2011AA ObjectClass
- C0370003
- NCI Thesaurus Property-2
- C25695
- UMLS 2011AA Property-2
- C1515023
Description
LabSpecimenIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ObjectClass
- C37984
- UMLS 2011AA ObjectClass
- C0022877
- NCI Thesaurus Property-2
- C19157
- UMLS 2011AA Property-2
- C0370003
Description
LabTransportIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ObjectClass
- C37984
- UMLS 2011AA ObjectClass
- C0022877
- NCI Thesaurus Property-2
- C61560
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
Description
ClinicalResearchAssociatePersonEmailAddressText
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus ObjectClass-2
- C25465
- UMLS 2011AA ObjectClass-2
- C1516627
- NCI Thesaurus Property
- C42775
- UMLS 2011AA Property
- C1705961
Description
ClinicalResearchAssociatePersonTelephoneNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25395
- UMLS 2011AA Property
- C0039457
- NCI Thesaurus ObjectClass-2
- C25465
- UMLS 2011AA ObjectClass-2
- C1516627
Similar models
For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box.
- StudyEvent: CALGB: Pharmacogenomic Submission and Quality Assurance Form
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
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C0011008 (UMLS 2011AA ValueDomain)
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C0421459 (UMLS CUI-1)
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C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
C1512698 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
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C1515023 (UMLS 2011AA Property-2)
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C1518422 (UMLS 2011AA Property)
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C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property-2)
C1515023 (UMLS 2011AA Property-2)
C0205394 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property)
C0040223 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property)
C0229664 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
C25452 (NCI Thesaurus Property)
C41277 (NCI Thesaurus Property-2)
C1561954 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0229664 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
CL267638 (NCI Metathesaurus Property)
C25452 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0018943 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
C62653 (NCI Thesaurus Property)
C2825051 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property-2)
C1515023 (UMLS 2011AA Property-2)
C62180 (NCI Thesaurus Property-3)
C0009264 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property-2)
C1515023 (UMLS 2011AA Property-2)
C0040223 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
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C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property-2)
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C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property-2)
C0370003 (UMLS 2011AA Property-2)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C61560 (NCI Thesaurus Property-2)
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)
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C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25465 (NCI Thesaurus ObjectClass-2)
C1516627 (UMLS 2011AA ObjectClass-2)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
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