ID

2056

Description

S0100 SPECIMEN SUBMISSION FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB420C1-7F40-419F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB420C1-7F40-419F-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 8/21/17 8/21/17 -
  3. 9/17/21 9/17/21 -
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Pathology - S0100 SPECIMEN SUBMISSION FORM - 2070809v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Specimen
Description

Specimen

Type of Specimen (select only one:)
Description

TypeofSpecimen

Data type

text

Tissue, specify site(s)
Description

Tissue,specifysites

Data type

text

Tissue state
Description

SpecimenState

Data type

text

Slides, type and number
Description

Slides,typeandnumber

Data type

text

Karotype(s), number
Description

Karotype(s),number

Data type

text

Date specimen collected
Description

SpecimenCollectionDate

Data type

date

Time specimen collected (24 hour time)
Description

SpecimenCollectionTime

Data type

date

Other, specify (type of specimen)
Description

Other,specify(typeofspecimen)

Data type

text

Reasons For Specimen Submission
Description

Reasons For Specimen Submission

Status (select all that apply:)
Description

SpecimenClinicalStatus

Data type

text

Other specimen, specify
Description

Otherspecimen,specify

Data type

text

Completed By
Description

CompletedBy

Data type

text

Date form completed
Description

FormCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C25367
Notes from submitting institution
Description

Comments

Data type

text

For Central Laboratory Use Only
Description

For Central Laboratory Use Only

Central laboratory identification number
Description

Centrallaboratoryidentificationnumber

Data type

text

Date specimen received
Description

SpecimenReceivedDate

Data type

date

Completed By
Description

CompletedBy

Data type

text

Time specimen received
Description

SpecimenReceivedTime

Data type

date

Date form completed
Description

FormCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C25367
Condition of specimen (select only one:)
Description

SpecimenCondition

Data type

text

Notes From Central Laboratory
Description

Notes From Central Laboratory

Ccrr Module For S0100 Specimen Submission Form
Description

Ccrr Module For S0100 Specimen Submission Form

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

Disease
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Institution/Affiliate
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
C25705
UMLS 2011AA ObjectClass
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
C25461
UMLS 2011AA ObjectClass
C0337611
Phone Number (Groups other than SWOG)
Description

PhoneNumber

Data type

double

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. ID
Description

Pt.ID

Data type

text

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No Instruction available.

1 forms
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Specimen
Item
Type of Specimen (select only one:)
text
CL.1
Code List
Type of Specimen (select 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(s))
CL Item
Other, Specify (Other)
Tissue,specifysites
Item
Tissue, specify site(s)
text
Item
Tissue state
text
CL.2
Code List
Tissue state
CL Item
Fresh (fresh)
CL Item
Frozen (frozen)
CL267638 (NCI Metathesaurus)
CL Item
Fixed (paraffin embedded)
Slides,typeandnumber
Item
Slides, type and number
text
Karotype(s),number
Item
Karotype(s), number
text
SpecimenCollectionDate
Item
Date specimen collected
date
SpecimenCollectionTime
Item
Time specimen collected (24 hour time)
date
Other,specify(typeofspecimen)
Item
Other, specify (type of specimen)
text
Item Group
Reasons For Specimen Submission
Item
Status (select all that apply:)
text
CL.3
Code List
Status (select all that apply:)
CL Item
Prestudy specimen (Prestudy specimen)
CL Item
Complete remission/response specimen (Complete remission/response specimen)
CL Item
Relapse/recurrence specimen (Relapse/recurrence specimen)
CL Item
Other specimen (Other specimen)
Otherspecimen,specify
Item
Other specimen, specify
text
CompletedBy
Item
Completed By
text
FormCompleteDate
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Comments
Item
Notes from submitting institution
text
Item Group
For Central Laboratory Use Only
Centrallaboratoryidentificationnumber
Item
Central laboratory identification number
text
SpecimenReceivedDate
Item
Date specimen received
date
CompletedBy
Item
Completed By
text
SpecimenReceivedTime
Item
Time specimen received
date
FormCompleteDate
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item
Condition of specimen (select only one:)
text
CL.4
Code List
Condition of specimen (select only one:)
CL Item
Useable (usable as received)
CL Item
Damaged Or Unusable (not usable as received; adequate submission)
CL Item
not usable as received; inadequate submission (not usable as received; inadequate submission)
Item Group
Notes From Central Laboratory
Item Group
Ccrr Module For S0100 Specimen Submission Form
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
Leukemia/MDSClassification
Item
Disease
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
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)
C1522326 (UMLS 2011AA ObjectClass)
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)
C0337611 (UMLS 2011AA ObjectClass)
PhoneNumber
Item
Phone Number (Groups other than SWOG)
double
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. ID
text
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