ID

2056

Beschreibung

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

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 21.08.17 21.08.17 -
  3. 17.09.21 17.09.21 -
Hochgeladen am

19. September 2012

DOI

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

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Specimen
Beschreibung

Specimen

Type of Specimen (select only one:)
Beschreibung

TypeofSpecimen

Datentyp

text

Tissue, specify site(s)
Beschreibung

Tissue,specifysites

Datentyp

text

Tissue state
Beschreibung

SpecimenState

Datentyp

text

Slides, type and number
Beschreibung

Slides,typeandnumber

Datentyp

text

Karotype(s), number
Beschreibung

Karotype(s),number

Datentyp

text

Date specimen collected
Beschreibung

SpecimenCollectionDate

Datentyp

date

Time specimen collected (24 hour time)
Beschreibung

SpecimenCollectionTime

Datentyp

date

Other, specify (type of specimen)
Beschreibung

Other,specify(typeofspecimen)

Datentyp

text

Reasons For Specimen Submission
Beschreibung

Reasons For Specimen Submission

Status (select all that apply:)
Beschreibung

SpecimenClinicalStatus

Datentyp

text

Other specimen, specify
Beschreibung

Otherspecimen,specify

Datentyp

text

Completed By
Beschreibung

CompletedBy

Datentyp

text

Date form completed
Beschreibung

FormCompleteDate

Datentyp

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
Beschreibung

Comments

Datentyp

text

For Central Laboratory Use Only
Beschreibung

For Central Laboratory Use Only

Central laboratory identification number
Beschreibung

Centrallaboratoryidentificationnumber

Datentyp

text

Date specimen received
Beschreibung

SpecimenReceivedDate

Datentyp

date

Completed By
Beschreibung

CompletedBy

Datentyp

text

Time specimen received
Beschreibung

SpecimenReceivedTime

Datentyp

date

Date form completed
Beschreibung

FormCompleteDate

Datentyp

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:)
Beschreibung

SpecimenCondition

Datentyp

text

Notes From Central Laboratory
Beschreibung

Notes From Central Laboratory

Ccrr Module For S0100 Specimen Submission Form
Beschreibung

Ccrr Module For S0100 Specimen Submission Form

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F, M)
Beschreibung

PatientInitials

Datentyp

text

Disease
Beschreibung

Leukemia/MDSClassification

Datentyp

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
Beschreibung

MainMemberInstitution/Affiliate

Datentyp

text

Physician
Beschreibung

TreatingPhysician

Datentyp

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
Beschreibung

ContactPersonatInstitution

Datentyp

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)
Beschreibung

PhoneNumber

Datentyp

double

Group Name
Beschreibung

GroupName

Datentyp

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.
Beschreibung

StudyNo.

Datentyp

text

Pt. ID
Beschreibung

Pt.ID

Datentyp

text

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No Instruction available.

1 Formulare
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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