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AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Sunitinib Malate in Treating HIV-Positive Patients With Cancer Undergoing Highly Active Antiretroviral Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

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Versionen (3)
  1. 26.08.12 26.08.12 -
  2. 08.07.15 08.07.15 -
  3. 08.07.15 08.07.15 -
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8. Juli 2015

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    AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
      1. No Instruction available.
    Header Module
    Beschreibung

    Header Module

    Visit number
    Beschreibung

    Visit number

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ObjectClass
    C16696
    NCI Thesaurus Property
    C25385
    UMLS CUI-1
    C1549755
    Study Coordinator's name
    Beschreibung

    Study Coordinator's name

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ObjectClass
    C25190
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C51880
    UMLS CUI-1
    C1515830
    UMLS CUI-2
    C1710220
    E-mail
    Beschreibung

    E-mail

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C42775
    UMLS CUI-1
    C1705961
    Phone Number (xxx-xxx-xxxx)
    Beschreibung

    Phone Number (xxx-xxx-xxxx)

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus Property
    C25395
    NCI Thesaurus ObjectClass
    C19711
    UMLS CUI-1
    C0039457
    Specimen information
    Beschreibung

    Specimen information

    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    Beschreibung

    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus Property
    C25452
    NCI Thesaurus Property-2
    C25275
    UMLS CUI-1
    C0011008
    UMLS CUI-2
    C0370003
    Specimen(s) obtained for donation to ACSR
    Beschreibung

    Specimen(s) obtained for donation to ACSR

    Datentyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C54153
    UMLS CUI-1
    C0370003
    UMLS CUI-2
    C1515830
    Specimen Type (check all that apply)
    Beschreibung

    Specimen Type (check all that apply)

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus Property
    C25695
    UMLS CUI-1
    C0370003
    UMLS CUI-2
    C1515023
    Other specify
    Beschreibung

    Other specify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    NCI Thesaurus Property
    C12508
    NCI Thesaurus Property-2
    C25683
    NCI Thesaurus ObjectClass
    C19157
    UMLS CUI-1
    C1521902
    UMLS CUI-2
    C0370003
    ACSR site the specimen(s) shipped to
    Beschreibung

    ACSR site the specimen(s) shipped to

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C54153
    UMLS CUI-1
    C1515830
    UMLS CUI-2
    C1524049
    Other, specify
    Beschreibung

    Other, specify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C54153
    UMLS CUI-1
    C1521902
    UMLS CUI-2
    C0370003
    If specimens were not obtained for ACSR, please indicate reason
    Beschreibung

    If specimens were not obtained for ACSR, please indicate reason

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C25594
    NCI Thesaurus Property-2
    C25695
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C1515830
    UMLS CUI-2
    C0392360
    Other, specify
    Beschreibung

    Other, specify

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    NCI Thesaurus ObjectClass-2
    C19707
    NCI Thesaurus Property
    C25594
    NCI Thesaurus Property-2
    C25695
    NCI Thesaurus ValueDomain
    C25685
    UMLS CUI-1
    C0370003
    UMLS CUI-2
    C1521902
    Comments
    Beschreibung

    Comments

    Comments
    Beschreibung

    Comments

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS CUI-1
    C0282411
    Zum Seitenanfang zurückkehren

    Ähnliche Modelle

    No Instruction available.

    1 Formulare
    1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Header Module
    Visit number
    Item
    Visit number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C25385 (NCI Thesaurus Property)
    C1549755 (UMLS CUI-1)
    Study Coordinator's name
    Item
    Study Coordinator's name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C51880 (NCI Thesaurus Property)
    C1515830 (UMLS CUI-1)
    C1710220 (UMLS CUI-2)
    Responsible Person E-mail
    Item
    E-mail
    text
    C25704 (NCI Thesaurus ValueDomain)
    C25657 (NCI Thesaurus ObjectClass)
    C42775 (NCI Thesaurus Property)
    C1705961 (UMLS CUI-1)
    Organization Phone Number
    Item
    Phone Number (xxx-xxx-xxxx)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25395 (NCI Thesaurus Property)
    C19711 (NCI Thesaurus ObjectClass)
    C0039457 (UMLS CUI-1)
    Item Group
    Specimen information
    Specimen Collected Date
    Item
    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C25452 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property-2)
    C0011008 (UMLS CUI-1)
    C0370003 (UMLS CUI-2)
    AIDS Malignancy Specimen Procurement
    Item
    Specimen(s) obtained for donation to ACSR
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C54153 (NCI Thesaurus Property)
    C0370003 (UMLS CUI-1)
    C1515830 (UMLS CUI-2)
    Item
    Specimen Type (check all that apply)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C25695 (NCI Thesaurus Property)
    C0370003 (UMLS CUI-1)
    C1515023 (UMLS CUI-2)
    CL.2
    Code List
    Specimen Type (check all that apply)
    CL Item
    Serum (Serum)
    C13325 (NCI Thesaurus)
    C13325 (NCI Thesaurus-3)
    C0229671 (UMLS CUI-1)
    CL Item
    Plasma (Plasma)
    C13356 (NCI Thesaurus)
    C13356 (NCI Thesaurus-3)
    C0032105 (UMLS CUI-1)
    CL Item
    peripheral Blood Mononuclear Cells (PBMC)
    C1321301 (UMLS CUI-1)
    CL Item
    Peripheral Blood (Blood)
    C0229664 (NCI Metathesaurus)
    C0229664 (NCI Metathesaurus-2)
    C0229664 (UMLS CUI-1)
    CL Item
    Tissue (Tissue)
    C12801 (NCI Thesaurus)
    C0040300 (UMLS CUI-1)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS CUI-1)
    Specimen Cell Source Specify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C12508 (NCI Thesaurus Property)
    C25683 (NCI Thesaurus Property-2)
    C19157 (NCI Thesaurus ObjectClass)
    C1521902 (UMLS CUI-1)
    C0370003 (UMLS CUI-2)
    Item
    ACSR site the specimen(s) shipped to
    text
    C25284 (NCI Thesaurus ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C54153 (NCI Thesaurus Property)
    C1515830 (UMLS CUI-1)
    C1524049 (UMLS CUI-2)
    CL.3
    Code List
    ACSR site the specimen(s) shipped to
    CL Item
    Gwu (GWU)
    CL Item
    Ucla (UCLA)
    C1517622 (UMLS CUI-1)
    CL Item
    Ucsf (UCSF)
    C1515354 (UMLS CUI-1)
    CL Item
    Osu (OSU)
    CL Item
    Suny/hscb (SUNY/HSCB)
    CL Item
    Jhu (JHU)
    C3828025 (UMLS CUI-1)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS CUI-1)
    AIDS Malignancy Consortium Specimen Specify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C54153 (NCI Thesaurus Property)
    C1521902 (UMLS CUI-1)
    C0370003 (UMLS CUI-2)
    Item
    If specimens were not obtained for ACSR, please indicate reason
    text
    C19157 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C25594 (NCI Thesaurus Property)
    C25695 (NCI Thesaurus Property-2)
    C25638 (NCI Thesaurus ValueDomain)
    C1515830 (UMLS CUI-1)
    C0392360 (UMLS CUI-2)
    CL.4
    Code List
    If specimens were not obtained for ACSR, please indicate reason
    CL Item
    Patient Had Previously Donated Specimen To Acsr (Patient had previously donated specimen to ACSR)
    CL Item
    Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused to give informed consent for ACSR specimen donation)
    CL Item
    Patient Was Not Asked To Consider Acsr Specimen Donation (Patient was not asked to consider ACSR specimen donation)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    AIDS Malignancy Consortium Not Submitted Specify
    Item
    Other, specify
    text
    C19157 (NCI Thesaurus ObjectClass)
    C19707 (NCI Thesaurus ObjectClass-2)
    C25594 (NCI Thesaurus Property)
    C25695 (NCI Thesaurus Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C0370003 (UMLS CUI-1)
    C1521902 (UMLS CUI-2)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS CUI-1)
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