ID

2087

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 21-08-17 21-08-17 -
  3. 17-09-21 17-09-21 -
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19 september 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Leukemia null Pathology - S0100 PATHOLOGY SUBMISSION FORM - 2070699v3.0

Engels

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

1 Formulieren  
Ccrr Module For S0100 Pathology Submission Form
Beschrijving

Ccrr Module For S0100 Pathology Submission Form

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

Patient Initials (L, F, M)
Beschrijving

PatientInitials

Datatype

text

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
Reason for Submission
Beschrijving

ReasonforSubmission

Datatype

text

No. of Slides
Beschrijving

SpecimenSlideCount

Datatype

text

Date Sample Obtained (month, day, year)
Beschrijving

SpecimenCollectionDate

Datatype

date

1 W Peripheral Smear Slide, Enclosed
Beschrijving

1WPeripheralSmearSlide,Enclosed

Datatype

text

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

1WGStainedBMAspirateSlide,Enclosed

Datatype

text

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

5UnstainedSmearSlides,Enclosed

Datatype

text

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

BMReport,Enclosed

Datatype

text

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

PathologySubmissionform-LeukemiaAddendum,Enclosed

Datatype

text

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

1Stainedbiopsytouchprep,Enclosed

Datatype

text

4 Unstained biopsy touch preps, Enclosed
Beschrijving

4Unstainedbiopsytouchpreps,Enclosed

Datatype

text

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

1H&Esectionofthebiopsy,Enclosed

Datatype

text

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

4Unstainedperipheralbloodsmears,Enclosed

Datatype

text

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

SpecimenID

Datatype

double

Notes
Beschrijving

Comments

Datatype

text

Terug naar het begin van de pagina

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

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
CL.1
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)
CL.2
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)
CL.3
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)
CL.4
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)
CL.5
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)
CL.6
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
CL.7
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)
CL.8
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)
CL.9
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)
CL.10
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
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