ID

2056

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 21-08-17 21-08-17 -
  3. 17-09-21 17-09-21 -
Geüploaded op

19 september 2012

DOI

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Licentie

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

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Specimen
Beschrijving

Specimen

Type of Specimen (select only one:)
Beschrijving

TypeofSpecimen

Datatype

text

Tissue, specify site(s)
Beschrijving

Tissue,specifysites

Datatype

text

Tissue state
Beschrijving

SpecimenState

Datatype

text

Slides, type and number
Beschrijving

Slides,typeandnumber

Datatype

text

Karotype(s), number
Beschrijving

Karotype(s),number

Datatype

text

Date specimen collected
Beschrijving

SpecimenCollectionDate

Datatype

date

Time specimen collected (24 hour time)
Beschrijving

SpecimenCollectionTime

Datatype

date

Other, specify (type of specimen)
Beschrijving

Other,specify(typeofspecimen)

Datatype

text

Reasons For Specimen Submission
Beschrijving

Reasons For Specimen Submission

Status (select all that apply:)
Beschrijving

SpecimenClinicalStatus

Datatype

text

Other specimen, specify
Beschrijving

Otherspecimen,specify

Datatype

text

Completed By
Beschrijving

CompletedBy

Datatype

text

Date form completed
Beschrijving

FormCompleteDate

Datatype

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
Beschrijving

Comments

Datatype

text

For Central Laboratory Use Only
Beschrijving

For Central Laboratory Use Only

Central laboratory identification number
Beschrijving

Centrallaboratoryidentificationnumber

Datatype

text

Date specimen received
Beschrijving

SpecimenReceivedDate

Datatype

date

Completed By
Beschrijving

CompletedBy

Datatype

text

Time specimen received
Beschrijving

SpecimenReceivedTime

Datatype

date

Date form completed
Beschrijving

FormCompleteDate

Datatype

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:)
Beschrijving

SpecimenCondition

Datatype

text

Notes From Central Laboratory
Beschrijving

Notes From Central Laboratory

Ccrr Module For S0100 Specimen Submission Form
Beschrijving

Ccrr Module For S0100 Specimen Submission Form

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F, M)
Beschrijving

PatientInitials

Datatype

text

Disease
Beschrijving

Leukemia/MDSClassification

Datatype

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
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
Beschrijving

TreatingPhysician

Datatype

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
Beschrijving

ContactPersonatInstitution

Datatype

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)
Beschrijving

PhoneNumber

Datatype

double

Group Name
Beschrijving

GroupName

Datatype

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.
Beschrijving

StudyNo.

Datatype

text

Pt. ID
Beschrijving

Pt.ID

Datatype

text

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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