ID

11400

Description

Southwest Oncology Group S0201 Specimen Submission Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA795E-3805-1204-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA795E-3805-1204-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group S0201 Specimen Submission Form

English

No Instruction available.

1 forms  
  1. StudyEvent: Southwest Oncology Group S0201 Specimen Submission Form
    1. No Instruction available.
SWOG clinical trial administrative data
Description

SWOG clinical trial administrative data

SWOG Patient No
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Reg Type
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Disease
Description

Disease

Data type

text

Institution/Member
Description

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

TreatingPhysician

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
Contact Person at Institution
Description

ContactPersonatInstitution

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C25461
UMLS 2011AA ObjectClass-2
C0337611
Telephone No. (Groups other than SWOG)
Description

PhoneNumber

Data type

float

Group Name
Description

GroupName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Description

StudyNo.

Data type

text

Pt. No
Description

Pt.ID

Data type

text

Specimen
Description

Specimen

Type of specimen (check only one)
Description

TypeofSpecimen

Data type

text

Tissue, specify sites
Description

Tissue,specifysites

Data type

text

Tissue, check one
Description

SpecimenState

Data type

text

Slides, type and number
Description

Slides,typeandnumber

Data type

text

karyotype, number
Description

KaryotypeCount

Data type

float

Date specimen collected
Description

SpecimenCollectionDate

Data type

date

Time specimen collected
Description

SpecimenCollectionTime

Data type

date

Reasons for specimen submission (Check all that apply)
Description

SpecimenSubmittedReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Other specimen, specify (reason for submission)
Description

Otherspecimen,specify(reasonforsubmission)

Data type

text

Treatment study No.
Description

SpecimenID

Data type

float

For Central Laboratory Use Only
Description

For Central Laboratory Use Only

Central laboratory identification number
Description

Centrallaboratoryidentificationnumber

Data type

text

Date
Description

SpecimenReceivedDate

Data type

date

time specimen received
Description

SpecimenReceivedTime

Data type

date

condition of specimen (check only one)
Description

SpecimenCondition

Data type

text

By
Description

By

Data type

text

Notes from central laboratory
Description

Comments

Data type

text

Date
Description

SpecimenSubmitDate

Data type

date

Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form
Description

Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Southwest Oncology Group S0201 Specimen Submission Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
SWOG clinical trial administrative data
SWOGPatientID
Item
SWOG Patient No
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Reg Type
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Disease
Item
Disease
text
MainMemberInstitution/Affiliate
Item
Institution/Member
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
ContactPersonatInstitution
Item
Contact Person at Institution
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass-2)
C0337611 (UMLS 2011AA ObjectClass-2)
PhoneNumber
Item
Telephone No. (Groups other than SWOG)
float
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. No
text
Item Group
Specimen
Item
Type of specimen (check only one)
text
CL.1
Code List
Type of specimen (check only one)
CL Item
Tubes Of Blood (tubes of blood)
CL Item
Tubes Of Bone Marrow (tubes of bone marrow)
CL Item
Tubes Of Serum (tubes of serum)
CL Item
Tissue, Specify Site(s) (tissue)
CL Item
Slides, Type And Number (slides)
CL Item
Karyotype(s), Number (karyotype)
CL Item
Other, Specify (other, specify)
Tissue,specifysites
Item
Tissue, specify sites
text
Item
Tissue, check one
text
CL.2
Code List
Tissue, check one
CL Item
Fresh (fresh)
CL Item
Frozen (frozen)
CL267638 (NCI Metathesaurus)
CL Item
parrafin embedded (parrafin embedded)
Slides,typeandnumber
Item
Slides, type and number
text
KaryotypeCount
Item
karyotype, number
float
SpecimenCollectionDate
Item
Date specimen collected
date
SpecimenCollectionTime
Item
Time specimen collected
date
Item
Reasons for specimen submission (Check all that apply)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
CL.3
Code List
Reasons for specimen submission (Check all that apply)
CL Item
Prestudy Submission (prestudy submission)
CL Item
Complete Remission/response Specimen (complete remission/response specimen)
CL Item
Relapse/recurrence Specimen (relapse/recurrence specimen)
CL Item
Other Specimen, Specify (other specimen, specify)
Otherspecimen,specify(reasonforsubmission)
Item
Other specimen, specify (reason for submission)
text
SpecimenID
Item
Treatment study No.
float
Item Group
For Central Laboratory Use Only
Centrallaboratoryidentificationnumber
Item
Central laboratory identification number
text
SpecimenReceivedDate
Item
Date
date
SpecimenReceivedTime
Item
time specimen received
date
Item
condition of specimen (check only one)
text
CL.4
Code List
condition of specimen (check only one)
CL Item
Useable (usable as received)
CL Item
Damaged Or Unusable (not usable as received; adequate submission)
CL Item
Damaged Or Unusable (not usable as received; inadequate submission)
By
Item
By
text
Comments
Item
Notes from central laboratory
text
SpecimenSubmitDate
Item
Date
date
Item Group
Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form
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