ID

1884

Descripción

CALGB: LEUKEMIA TISSUE BANK SPECIMEN ROUTING FORM Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F365-AE89-5149-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F365-AE89-5149-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 25/7/17 25/7/17 - Martin Dugas
Subido en

19 de septiembre de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0
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Leukemia NCT00085124 Pathology - CALGB: LEUKEMIA TISSUE BANK SPECIMEN ROUTING FORM - 2076722v3.0

Inglés

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 formularios  
To Be Completed By Institution
Descripción

To Be Completed By Institution

Specimen Type
Descripción

TypeofSpecimen

Tipo de datos

text

Time Specimen Collected (24 hour clock)
Descripción

SpecimenCollectionTime

Tipo de datos

date

Date Specimen Collected (M D Y)
Descripción

SpecimenCollectionDate

Tipo de datos

date

Diagnosis
Descripción

HematopoieticDiagnosis

Tipo de datos

text

Sample Period
Descripción

SamplePeriod

Tipo de datos

text

Sample Extraction Method
Descripción

SpecimenCollectionMethod

Tipo de datos

text

Sample Preparation Method
Descripción

SamplePreparationMethod

Tipo de datos

text

Sample Container
Descripción

SampleContainer

Tipo de datos

text

Number of Tubes Submitted
Descripción

Numberoftubessubmitted

Tipo de datos

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
Are the tubes labeled
Descripción

Arethetubeslabeled

Tipo de datos

text

If not, please explain (why tubes are not labeled)
Descripción

Ifnot,pleaseexplain(whytubesarenotlabeled)

Tipo de datos

text

Pathology Report Submitted to Data Management Center for this Sample Period
Descripción

Pathologyreports(ind)

Tipo de datos

text

Completed By (Print or Type Name)
Descripción

CompletedBy

Tipo de datos

text

Date Completed
Descripción

FormOriginalCompleteDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
Phone Number (Include Beeper # or Extension)
Descripción

PersonCompletingForm,Phone

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Lab Use Only
Descripción

Lab Use Only

LAB SAMPLE ID #
Descripción

SpecimenID

Tipo de datos

double

Number of Tubes Banked
Descripción

SpecimenVialTissueCollectionSubmissionCount

Tipo de datos

double

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Thesaurus Property
C41275
UMLS 2011AA Property
C0184301
NCI Thesaurus Property
C15339
UMLS 2011AA Property
C0040278
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Average Volume Per Tube (ml)
Descripción

SpecimenVialTissueCollectionSubmissionAverageVolumeMeasurement

Tipo de datos

double

Unidades de medida
  • ml
Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Thesaurus Property
C41275
UMLS 2011AA Property
C0184301
NCI Thesaurus Property
C15339
UMLS 2011AA Property
C0040278
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
NCI Thesaurus ValueDomain
C25335
UMLS 2011AA ValueDomain
C0449468
NCI Thesaurus ValueDomain
C37917
UMLS 2011AA ValueDomain
C1510992
ml
Sample Storage
Descripción

SampleStorage

Tipo de datos

text

Sample Condition
Descripción

SpecimenCondition

Tipo de datos

text

Completed By (Print or Type Name)
Descripción

CompletedBy

Tipo de datos

text

Date Completed
Descripción

FormOriginalCompleteDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
Ccrr Module For Calgb: Leukemia Tissue Bank Specimen Routing Form
Descripción

Ccrr Module For Calgb: Leukemia Tissue Bank Specimen Routing Form

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBProtocolNumber

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient?s Name
Descripción

Patient'sName

Tipo de datos

text

Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroupName

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientID

Tipo de datos

text

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Similar models

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
To Be Completed By Institution
Item
Specimen Type
text
CL.1
Code List
Specimen Type
CL Item
Tubes Of Blood (Peripheral Blood)
CL Item
Tubes Of Bone Marrow (Bone Marrow)
CL Item
Tissue, Specify Site(s) (Tissue)
CL Item
Other, Specify (Buccal Cells)
SpecimenCollectionTime
Item
Time Specimen Collected (24 hour clock)
date
SpecimenCollectionDate
Item
Date Specimen Collected (M D Y)
date
Item
Diagnosis
text
CL.2
Code List
Diagnosis
CL Item
APL (APL)
CL Item
AML (AML)
CL Item
ALL (ALL)
CL Item
CLL (CLL)
CL Item
CML (CML)
CL Item
MDS (MDS)
CL Item
AUL (AUL)
Item
Sample Period
text
CL.3
Code List
Sample Period
CL Item
Sample Or Specimen Collected Before Patient Received Treatment For Cancer (Pre-treatment)
CL Item
Sample Or Specimen Collected After Patient Received Treatment For Cancer (Post-treatment)
CL Item
Remission (Remission)
CL Item
Relapse (Relapse)
CL Item
Maintenance (Maintenance)
CL Item
Follow-up Off Treatment (Follow-up Off Treatment)
CL Item
Residual Disease (Residual Disease)
CL Item
Initial Treatment (Initial Treatment)
CL Item
After Course I (After Course I)
CL Item
After Course III (After Course III)
CL Item
After Course VI (After Course VI)
CL Item
3 months (3 months)
CL Item
6 months (6 months)
CL Item
9 months (9 months)
CL Item
Follow-up Sample (q 6 months) (Follow-up Sample (q 6 months))
CL Item
Follow-up Sample (q 12 months) (Follow-up Sample (q 12 months))
CL Item
At Diagnosis (At Diagnosis)
CL Item
Prior to Intensification (Prior to Intensification)
CL Item
Post Completion of Intensification (Post Completion of Intensification)
CL Item
Post IL-2 (Post IL-2)
CL Item
Every 4 months (Every 4 months)
CL Item
3 years post diagnosis (3 years post diagnosis)
CL Item
Follow-up (Follow-up)
Item
Sample Extraction Method
text
CL.4
Code List
Sample Extraction Method
CL Item
Small Bore Aspirate (Small Bore Aspirate)
CL Item
Large Bore Aspirate (Large Bore Aspirate)
CL Item
Venous (Venous)
CL Item
Swab (Swab)
Item
Sample Preparation Method
text
CL.5
Code List
Sample Preparation Method
CL Item
Air Dry Smear (Air Dry Smear)
CL Item
Touch Prep (Touch Prep)
CL Item
Buccal Swab (Buccal Swab)
CL Item
Fresh (Fresh)
Item
Sample Container
text
CL.6
Code List
Sample Container
CL Item
Purple Top Vial (Purple Top Vial)
CL Item
Green Top Vial (Green Top Vial)
CL Item
Conical Screw Top Vial (Conical Screw Top Vial)
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)
Item
Are the tubes labeled
text
CL.7
Code List
Are the tubes labeled
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Ifnot,pleaseexplain(whytubesarenotlabeled)
Item
If not, please explain (why tubes are not labeled)
text
Item
Pathology Report Submitted to Data Management Center for this Sample Period
text
CL.8
Code List
Pathology Report Submitted to Data Management Center for this Sample Period
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CompletedBy
Item
Completed By (Print or Type Name)
text
FormOriginalCompleteDate
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
PersonCompletingForm,Phone
Item
Phone Number (Include Beeper # or Extension)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item Group
Lab Use Only
SpecimenID
Item
LAB SAMPLE ID #
double
SpecimenVialTissueCollectionSubmissionCount
Item
Number of Tubes Banked
double
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C41275 (NCI Thesaurus Property)
C0184301 (UMLS 2011AA Property)
C15339 (NCI Thesaurus Property)
C0040278 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
SpecimenVialTissueCollectionSubmissionAverageVolumeMeasurement
Item
Average Volume Per Tube (ml)
double
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C41275 (NCI Thesaurus Property)
C0184301 (UMLS 2011AA Property)
C15339 (NCI Thesaurus Property)
C0040278 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C25335 (NCI Thesaurus ValueDomain)
C0449468 (UMLS 2011AA ValueDomain)
C37917 (NCI Thesaurus ValueDomain)
C1510992 (UMLS 2011AA ValueDomain)
Item
Sample Storage
text
CL.9
Code List
Sample Storage
CL Item
Room Temperature (room temperature)
CL Item
4 Degrees Celsius (4 degrees celsius)
CL Item
Frozen-dry Ice (frozen-dry ice)
CL Item
Frozen-liquid Nitrogen (frozen-liquid nitrogen)
CL Item
Frozen-ice Packs (frozen-ice packs)
CL Item
Fresh-wet Ice (fresh-wet ice)
CL Item
Minus 20 Degrees Celsius (minus 20 degrees celsius)
CL Item
Minus 70 Degrees Celsius (minus 70 degrees celsius)
Item
Sample Condition
text
CL.10
Code List
Sample Condition
CL Item
Useable (OK)
CL Item
Damaged Or Unusable (damaged)
CL Item
No Specimen Received (missing)
CL Item
too old (too old)
CL Item
poor viability (poor viability)
CL Item
thawed (thawed)
CL Item
insufficient amount (insufficient amount)
CL Item
low blast count (low blast count)
CL Item
low tumor count (low tumor count)
CL Item
no positive tumor (no positive tumor)
CL Item
poor fixation (poor fixation)
CL Item
clotted (clotted)
CL Item
thawed, cold (thawed, cold)
CL Item
thawed, warm (thawed, warm)
CL Item
frozen (frozen)
CompletedBy
Item
Completed By (Print or Type Name)
text
FormOriginalCompleteDate
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
Item Group
Ccrr Module For Calgb: Leukemia Tissue Bank Specimen Routing Form
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)
CL.11
Code List
Amended data
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient?s Name
text
PatientHospitalNumber
Item
Patient Hospital Number
text
MainMemberInstitution/Affiliate
Item
Main Member Institution/Adjunct
text
ParticipatingGroupName
Item
Participating Group
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
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