ID

23938

Description

Infection NCT00513526 Pathology - AMC-052 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) - 2676606v1.0 AMC-052 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Human Papillomavirus Vaccine Therapy in Treating Men With HIV-1 Infection Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3952E724-4079-361E-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3952E724-4079-361E-E044-0003BA3F9857

Mots-clés

Versions (2)
  1. 19/09/2012 19/09/2012 -
  2. 19/07/2017 19/07/2017 - Martin Dugas
Téléchargé le

19 juillet 2017

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
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HIV HPV Vaccine NCT00513526 AMC-052

Anglais

No Instruction available.

1 Formulaires  
  1. StudyEvent: AMC-052 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Description

Hospital Admission Number

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
Study Coordinator's name
Description

AIDSMalignancyConsortiumPersonStudyCoordinatorName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C51880
UMLS CUI [1]
C1710220
E-mail
Description

ResponsiblePersonE-mailAddressText

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C42775
UMLS CUI [1]
C0013849
Phone Number
Description

Phone Number

Type de données

text

Unités de mesure
  • (xxx-xxx-xxxx)
Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25395
NCI Thesaurus ObjectClass
C19711
UMLS CUI [1]
C1515258
(xxx-xxx-xxxx)
Comments
Description

Research Comments

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1]
C0947611
Specimen Procurement
Description

Specimen Procurement

Alias
UMLS CUI-1
C0370003
UMLS CUI-2
C1709695
Specimen(s) obtained for donation to ACSR
Description

AIDSMalignancyConsortiumSpecimenProcurementInd-2

Type de données

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1]
C0680854
Specimen Type (check all that apply)
Description

Specimen Type

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25695
UMLS CUI [1]
C0456204
Other specify
Description

Specimen Source

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C12508
NCI Thesaurus Property-2
C25683
NCI Thesaurus ObjectClass
C19157
UMLS CUI [1,1]
C0449416
UMLS CUI [1,2]
C0370003
ACSR site the specimen(s) shipped to
Description

AIDSMalignancyConsortiumSpecimenProcurementType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1]
C0450429
Other, specify
Description

AIDSMalignancyConsortiumSpecimenProcurementSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1]
C0450429
If specimens were not obtained for ACSR, please indicate reason
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedReason

Type de données

text

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C25594
NCI Thesaurus Property-2
C25695
NCI Thesaurus ValueDomain
C25638
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3640292
Other reason, specify
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C25594
NCI Thesaurus Property-2
C25695
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3640292
Collection date
Description

Specimen Collection Date

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25452
NCI Thesaurus Property-2
C25275
UMLS CUI [1]
C1302413
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Similar models

No Instruction available.

1 Formulaires
  1. StudyEvent: AMC-052 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Hospital Admission Number
Item
Visit number
text
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
Study coordinator
Item
Study Coordinator's name
text
C25191 (NCI Thesaurus ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C51880 (NCI Thesaurus Property)
C1710220 (UMLS CUI [1])
Email
Item
E-mail
text
C25704 (NCI Thesaurus ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C42775 (NCI Thesaurus Property)
C0013849 (UMLS CUI [1])
Phone Number
Item
Phone Number
text
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus Property)
C19711 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI [1])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1])
Item Group
Specimen Procurement
C0370003 (UMLS CUI-1)
C1709695 (UMLS CUI-2)
Donation
Item
Specimen(s) obtained for donation to ACSR
boolean
C38147 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0680854 (UMLS CUI [1])
Item
Specimen Type (check all that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C0456204 (UMLS CUI [1])
CL.2
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
C13325 (NCI Thesaurus)
C13325 (NCI Thesaurus-3)
C0229671 (UMLS CUI-1)
(Comment:en)
CL Item
Plasma (Plasma)
C13356 (NCI Thesaurus)
C13356 (NCI Thesaurus-3)
C0032105 (UMLS CUI-1)
(Comment:en)
CL Item
PBMC (peripheral Blood Mononuclear Cells) (PBMC)
C1321301 (UMLS CUI-1)
(Comment:en)
CL Item
Peripheral Blood (Blood)
C0229664 (NCI Metathesaurus)
C0229664 (NCI Metathesaurus-2)
C0229664 (UMLS CUI-1)
(Comment:en)
CL Item
Tissue (Tissue)
C12801 (NCI Thesaurus)
C0040300 (UMLS CUI-1)
(Comment:en)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS CUI-1)
(Comment:en)
Specimen Source
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C12508 (NCI Thesaurus Property)
C25683 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0449416 (UMLS CUI [1,1])
C0370003 (UMLS CUI [1,2])
Item
ACSR site the specimen(s) shipped to
text
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0450429 (UMLS CUI [1])
CL.3
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucla (UCLA)
CL Item
Ucsf (UCSF)
CL Item
Osu (OSU)
CL Item
Suny/hscb (SUNY/HSCB)
CL Item
Jhu (JHU)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Site, other
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C0450429 (UMLS CUI [1])
Item
If specimens were not obtained for ACSR, please indicate reason
text
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25638 (NCI Thesaurus ValueDomain)
C0566251 (UMLS CUI [1,1])
C3640292 (UMLS CUI [1,2])
CL.4
Code List
If specimens were not obtained for ACSR, please indicate reason
CL Item
Patient Had Previously Donated Specimen To Acsr (Patient had previously donated specimen to ACSR)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused to give informed consent for ACSR specimen donation)
CL Item
Patient Was Not Asked To Consider Acsr Specimen Donation (Patient was not asked to consider ACSR specimen donation)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Reason no specimen
Item
Other reason, specify
text
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C25594 (NCI Thesaurus Property)
C25695 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
C0566251 (UMLS CUI [1,1])
C3640292 (UMLS CUI [1,2])
Specimen Collection Date
Item
Collection date
date
C25164 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C1302413 (UMLS CUI [1])
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