ID

1884

Beskrivning

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

Länk

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

Nyckelord

Versioner (2)
  1. 2012-09-19 2012-09-19 -
  2. 2017-07-25 2017-07-25 - Martin Dugas
Uppladdad den

19 september 2012

DOI

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

Engelsk

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 Formulär  
To Be Completed By Institution
Beskrivning

To Be Completed By Institution

Specimen Type
Beskrivning

TypeofSpecimen

Datatyp

text

Time Specimen Collected (24 hour clock)
Beskrivning

SpecimenCollectionTime

Datatyp

date

Date Specimen Collected (M D Y)
Beskrivning

SpecimenCollectionDate

Datatyp

date

Diagnosis
Beskrivning

HematopoieticDiagnosis

Datatyp

text

Sample Period
Beskrivning

SamplePeriod

Datatyp

text

Sample Extraction Method
Beskrivning

SpecimenCollectionMethod

Datatyp

text

Sample Preparation Method
Beskrivning

SamplePreparationMethod

Datatyp

text

Sample Container
Beskrivning

SampleContainer

Datatyp

text

Number of Tubes Submitted
Beskrivning

Numberoftubessubmitted

Datatyp

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
Beskrivning

Arethetubeslabeled

Datatyp

text

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

Ifnot,pleaseexplain(whytubesarenotlabeled)

Datatyp

text

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

Pathologyreports(ind)

Datatyp

text

Completed By (Print or Type Name)
Beskrivning

CompletedBy

Datatyp

text

Date Completed
Beskrivning

FormOriginalCompleteDate

Datatyp

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)
Beskrivning

PersonCompletingForm,Phone

Datatyp

text

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

Lab Use Only

LAB SAMPLE ID #
Beskrivning

SpecimenID

Datatyp

double

Number of Tubes Banked
Beskrivning

SpecimenVialTissueCollectionSubmissionCount

Datatyp

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)
Beskrivning

SpecimenVialTissueCollectionSubmissionAverageVolumeMeasurement

Datatyp

double

Måttenheter
  • 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
Beskrivning

SampleStorage

Datatyp

text

Sample Condition
Beskrivning

SpecimenCondition

Datatyp

text

Completed By (Print or Type Name)
Beskrivning

CompletedBy

Datatyp

text

Date Completed
Beskrivning

FormOriginalCompleteDate

Datatyp

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
Beskrivning

Ccrr Module For Calgb: Leukemia Tissue Bank Specimen Routing Form

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBProtocolNumber

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Amended data
Beskrivning

AmendedDataInd

Datatyp

text

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

Patient'sName

Datatyp

text

Patient Hospital Number
Beskrivning

PatientHospitalNumber

Datatyp

text

Main Member Institution/Adjunct
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Participating Group
Beskrivning

ParticipatingGroupName

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Participating Group Patient No.
Beskrivning

ParticipatingGroupPatientID

Datatyp

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 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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