ID

2087

Description

S0100 PATHOLOGY SUBMISSION FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB412F0-20C0-418F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB412F0-20C0-418F-E034-0003BA12F5E7

Keywords

  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

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Leukemia null Pathology - S0100 PATHOLOGY SUBMISSION FORM - 2070699v3.0

Instructions: Submit a copy of this form to the SWOG Statistical Center. Mail required materials and this form to the following pathologist: David Head, MD Vanderbilt Clinical Labs 4605 TVC 1161 21st Ave. S. Nashville, TN 37232

Ccrr Module For S0100 Pathology Submission Form
Description

Ccrr Module For S0100 Pathology Submission Form

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

SWOG Patient ID
Description

SWOGPatientID

Data type

text

Patient Initials (L, F, M)
Description

PatientInitials

Data type

text

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
Reason for Submission
Description

ReasonforSubmission

Data type

text

No. of Slides
Description

SpecimenSlideCount

Data type

text

Date Sample Obtained (month, day, year)
Description

SpecimenCollectionDate

Data type

date

1 W Peripheral Smear Slide, Enclosed
Description

1WPeripheralSmearSlide,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
1 WG Stained BM Aspirate Slide, Enclosed
Description

1WGStainedBMAspirateSlide,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
5 Unstained Smear Slides, Enclosed
Description

5UnstainedSmearSlides,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
BM Report, Enclosed
Description

BMReport,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pathology Submission form - Leukemia Addendum, Enclosed
Description

PathologySubmissionform-LeukemiaAddendum,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
1 Stained biopsy touch prep, Enclosed
Description

1Stainedbiopsytouchprep,Enclosed

Data type

text

4 Unstained biopsy touch preps, Enclosed
Description

4Unstainedbiopsytouchpreps,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
1 H&E section of the biopsy, Enclosed
Description

1H&Esectionofthebiopsy,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
4 Unstained peripheral blood smears, Enclosed
Description

4Unstainedperipheralbloodsmears,Enclosed

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specimen #
Description

SpecimenID

Data type

double

Notes
Description

Comments

Data type

text

Similar models

Instructions: Submit a copy of this form to the SWOG Statistical Center. Mail required materials and this form to the following pathologist: David Head, MD Vanderbilt Clinical Labs 4605 TVC 1161 21st Ave. S. Nashville, TN 37232

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For S0100 Pathology Submission Form
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
SWOGPatientID
Item
SWOG Patient ID
text
PatientInitials
Item
Patient Initials (L, F, M)
text
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)
Item
Reason for Submission
text
Code List
Reason for Submission
CL Item
Prestudy (Prestudy)
SpecimenSlideCount
Item
No. of Slides
text
SpecimenCollectionDate
Item
Date Sample Obtained (month, day, year)
date
Item
1 W Peripheral Smear Slide, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
1 W Peripheral Smear Slide, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
1 WG Stained BM Aspirate Slide, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
1 WG Stained BM Aspirate Slide, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
5 Unstained Smear Slides, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
5 Unstained Smear Slides, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
BM Report, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
BM Report, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Pathology Submission form - Leukemia Addendum, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Pathology Submission form - Leukemia Addendum, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
1 Stained biopsy touch prep, Enclosed
text
Code List
1 Stained biopsy touch prep, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
4 Unstained biopsy touch preps, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
4 Unstained biopsy touch preps, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
1 H&E section of the biopsy, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
1 H&E section of the biopsy, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
4 Unstained peripheral blood smears, Enclosed
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
4 Unstained peripheral blood smears, Enclosed
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
SpecimenID
Item
Specimen #
double
Comments
Item
Notes
text

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial