ID

24085

Description

CALGB: LEUKEMIA TISSUE BANK SPECIMEN ROUTING FORM Leukemia NCT00085124 Pathology - CALGB: LEUKEMIA TISSUE BANK SPECIMEN ROUTING FORM - 2076722v3.0 Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F365-AE89-5149-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F365-AE89-5149-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/25/17 7/25/17 - Martin Dugas
Uploaded on

July 25, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Leukemia Daunorubicin and Cytarabine NCT00085124 CALGB

English

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms  
Specimen information
Description

Specimen information

Alias
UMLS CUI-1
C0370003
Specimen Type
Description

Type of Specimen

Data type

text

Alias
UMLS CUI [1]
C0456204
Time Specimen Collected
Description

Specimen collection time

Data type

time

Alias
UMLS CUI [1]
C4064021
Collection date
Description

Specimen Collection Date

Data type

date

Alias
UMLS CUI [1]
C1302413
Diagnosis
Description

Hematopoietic Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0018939
Sample Period
Description

Sample Period

Data type

text

Alias
UMLS CUI [1,1]
C0370003
UMLS CUI [1,2]
C1948053
Sample Extraction Method
Description

Specimen Collection Method

Data type

text

Alias
UMLS CUI [1]
C1547864
Sample Preparation Method
Description

Sample Preparation Method

Data type

text

Alias
UMLS CUI [1]
C0939975
Sample Container
Description

Sample Container

Data type

text

Alias
UMLS CUI [1]
C0460055
Number of Tubes Submitted
Description

Number of tubes

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C41277
NCI Thesaurus Property
C25695
UMLS CUI [1,1]
C1561954
UMLS CUI [1,2]
C0750480
Are the tubes labeled
Description

tubes labeled

Data type

boolean

Alias
UMLS CUI [1,1]
C1561954
UMLS CUI [1,2]
C1708632
If not, please explain (why tubes are not labeled)
Description

sample unlabeled, reason

Data type

text

Alias
UMLS CUI [1,1]
C0475878
UMLS CUI [1,2]
C0566251
Pathology Report Submitted to Data Management Center for this Sample Period
Description

Pathology report

Data type

boolean

Alias
UMLS CUI [1]
C0807321
Completed By (Print or Type Name)
Description

Completed By

Data type

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Description

Form Original Complete Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1549507
Phone Number (Include Beeper # or Extension)
Description

Phone number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI [1]
C1515258
Lab Use Only
Description

Lab Use Only

Alias
UMLS CUI-1
C3846506
LAB SAMPLE ID #
Description

Specimen ID

Data type

text

Alias
UMLS CUI [1]
C1299222
Number of Tubes Banked
Description

Tubes banked

Data type

integer

Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25695
NCI Thesaurus Property-2
C41275
NCI Thesaurus Property-3
C15339
NCI Thesaurus ValueDomain
C25463
UMLS CUI [1,1]
C1561954
UMLS CUI [1,2]
C0750480
Average Volume Per Tube
Description

SpecimenVialTissueCollectionSubmissionAverageVolumeMeasurement

Data type

float

Measurement units
  • ml
Alias
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25695
NCI Thesaurus Property-2
C41275
NCI Thesaurus Property-3
C15339
NCI Thesaurus ValueDomain
C25209
NCI Thesaurus ValueDomain-2
C25335
NCI Thesaurus ValueDomain-3
C37917
UMLS CUI [1,1]
C1561954
UMLS CUI [1,2]
C0449468
UMLS CUI [1,3]
C1510992
ml
Sample Storage
Description

Sample Storage

Data type

text

Alias
UMLS CUI [1,1]
C0370003
UMLS CUI [1,2]
C1698986
Sample Condition
Description

Specimen Condition

Data type

text

Alias
UMLS CUI [1]
C1547869
Completed By (Print or Type Name)
Description

Completed By

Data type

text

Alias
UMLS CUI [1]
C1550483
Date Completed
Description

Form Original Complete Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1549507
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBProtocolNumber

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended data
Description

AmendedDataInd

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI [1,1]
C1511726
UMLS CUI [1,2]
C1691222
Patient?s Name
Description

Patient'sName

Data type

text

Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Affiliate

Data type

text

Participating Group
Description

ParticipatingGroupName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientID

Data type

text

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Similar models

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Specimen information
C0370003 (UMLS CUI-1)
Item
Specimen Type
text
C0456204 (UMLS CUI [1])
CL.1
Code List
Specimen Type
CL Item
Tubes Of Blood (Peripheral Blood)
C0229664 (UMLS CUI-1)
(Comment:en)
CL Item
Tubes Of Bone Marrow (Bone Marrow)
C0005953 (UMLS CUI-1)
(Comment:en)
CL Item
Tissue, Specify Site(s) (Tissue)
C0040300 (UMLS CUI-1)
(Comment:en)
CL Item
Other, Specify (Buccal Cells)
C3845569 (UMLS CUI-1)
(Comment:en)
Specimen collection time
Item
Time Specimen Collected
time
C4064021 (UMLS CUI [1])
Specimen Collection Date
Item
Collection date
date
C1302413 (UMLS CUI [1])
Item
Diagnosis
text
C0018939 (UMLS CUI [1])
CL.2
Code List
Diagnosis
CL Item
APL (APL)
C0023487 (UMLS CUI-1)
(Comment:en)
CL Item
AML (AML)
C0023467 (UMLS CUI-1)
(Comment:en)
CL Item
ALL (ALL)
C0023449 (UMLS CUI-1)
(Comment:en)
CL Item
CLL (CLL)
C0023434 (UMLS CUI-1)
(Comment:en)
CL Item
CML (CML)
C0023473 (UMLS CUI-1)
(Comment:en)
CL Item
MDS (MDS)
C3463824 (UMLS CUI-1)
(Comment:en)
CL Item
AUL (AUL)
C0280141 (UMLS CUI-1)
(Comment:en)
Item
Sample Period
text
C0370003 (UMLS CUI [1,1])
C1948053 (UMLS CUI [1,2])
CL.3
Code List
Sample Period
CL Item
Sample Or Specimen Collected Before Patient Received Treatment For Cancer (Pre-treatment)
C2709094 (UMLS CUI-1)
(Comment:en)
CL Item
Sample Or Specimen Collected After Patient Received Treatment For Cancer (Post-treatment)
C2709088 (UMLS CUI-1)
(Comment:en)
CL Item
Remission (Remission)
C0544452 (UMLS CUI-1)
(Comment:en)
CL Item
Relapse (Relapse)
C0035020 (UMLS CUI-1)
(Comment:en)
CL Item
Maintenance (Maintenance)
C0481504 (UMLS CUI-1)
(Comment:en)
CL Item
Follow-up Off Treatment (Follow-up Off Treatment)
C1522577 (UMLS CUI-1)
C1518544 (UMLS CUI-2)
(Comment:en)
CL Item
Residual Disease (Residual Disease)
C0543478 (UMLS CUI-1)
(Comment:en)
CL Item
Initial Treatment (Initial Treatment)
C0087111 (UMLS CUI-1)
C0205265 (UMLS CUI-2)
(Comment:en)
CL Item
After Course I (After Course I)
(Comment:en)
CL Item
After Course III (After Course III)
(Comment:en)
CL Item
After Course VI (After Course VI)
(Comment:en)
CL Item
3 months (3 months)
C1442461 (UMLS CUI-1)
(Comment:en)
CL Item
6 months (6 months)
(Comment:en)
CL Item
9 months (9 months)
(Comment:en)
CL Item
Follow-up Sample (q 6 months) (Follow-up Sample (q 6 months))
(Comment:en)
CL Item
Follow-up Sample (q 12 months) (Follow-up Sample (q 12 months))
(Comment:en)
CL Item
At Diagnosis (At Diagnosis)
C0441942 (UMLS CUI-1)
(Comment:en)
CL Item
Prior to Intensification (Prior to Intensification)
(Comment:en)
CL Item
Post Completion of Intensification (Post Completion of Intensification)
(Comment:en)
CL Item
Post IL-2 (Post IL-2)
(Comment:en)
CL Item
Every 4 months (Every 4 months)
C0585338 (UMLS CUI-1)
(Comment:en)
CL Item
3 years post diagnosis (3 years post diagnosis)
(Comment:en)
CL Item
Follow-up (Follow-up)
C1522577 (UMLS CUI-1)
(Comment:en)
Item
Sample Extraction Method
text
C1547864 (UMLS CUI [1])
CL.4
Code List
Sample Extraction Method
CL Item
Venous (Venous)
C0348013 (UMLS CUI-1)
(Comment:en)
CL Item
Swab (Swab)
C1261188 (UMLS CUI-1)
(Comment:en)
CL Item
Small Bone Marrow Aspirate (Small Bone Aspirate)
C1271729 (UMLS CUI-1)
(Comment:en)
CL Item
Large Bone Marrow Aspirate (Large Bone Aspirate)
C1271729 (UMLS CUI-1)
(Comment:en)
Item
Sample Preparation Method
text
C0939975 (UMLS CUI [1])
CL.5
Code List
Sample Preparation Method
CL Item
Air Dry Smear (Air Dry Smear)
C0444086 (UMLS CUI-1)
C1879673 (UMLS CUI-2)
(Comment:en)
CL Item
Touch Prep (Touch Prep)
C2827487 (UMLS CUI-1)
(Comment:en)
CL Item
Buccal Swab (Buccal Swab)
C2207146 (UMLS CUI-1)
(Comment:en)
CL Item
Fresh (Fresh)
C2827486 (UMLS CUI-1)
(Comment:en)
Item
Sample Container
text
C0460055 (UMLS CUI [1])
CL.6
Code List
Sample Container
CL Item
Purple Top Vial (Purple Top Vial)
CL Item
Green Top Vial (Green Top Vial)
CL Item
Conical Screw Top Vial (Conical Screw Top Vial)
Number of tubes
Item
Number of Tubes Submitted
integer
C25337 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C41277 (NCI Thesaurus ObjectClass-2)
C25695 (NCI Thesaurus Property)
C1561954 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
tubes labeled
Item
Are the tubes labeled
boolean
C1561954 (UMLS CUI [1,1])
C1708632 (UMLS CUI [1,2])
sample unlabeled, reason
Item
If not, please explain (why tubes are not labeled)
text
C0475878 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Pathology report
Item
Pathology Report Submitted to Data Management Center for this Sample Period
boolean
C0807321 (UMLS CUI [1])
Completed By
Item
Completed By (Print or Type Name)
text
C1550483 (UMLS CUI [1])
Form Original Complete Date
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI [1])
Phone number
Item
Phone Number (Include Beeper # or Extension)
text
C25704 (NCI Thesaurus ValueDomain)
C1515258 (UMLS CUI [1])
Item Group
Lab Use Only
C3846506 (UMLS CUI-1)
Specimen ID
Item
LAB SAMPLE ID #
text
C1299222 (UMLS CUI [1])
Tubes banked
Item
Number of Tubes Banked
integer
C19157 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C41275 (NCI Thesaurus Property-2)
C15339 (NCI Thesaurus Property-3)
C25463 (NCI Thesaurus ValueDomain)
C1561954 (UMLS CUI [1,1])
C0750480 (UMLS CUI [1,2])
Volume Per Tube
Item
Average Volume Per Tube
float
C19157 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C41275 (NCI Thesaurus Property-2)
C15339 (NCI Thesaurus Property-3)
C25209 (NCI Thesaurus ValueDomain)
C25335 (NCI Thesaurus ValueDomain-2)
C37917 (NCI Thesaurus ValueDomain-3)
C1561954 (UMLS CUI [1,1])
C0449468 (UMLS CUI [1,2])
C1510992 (UMLS CUI [1,3])
Item
Sample Storage
text
C0370003 (UMLS CUI [1,1])
C1698986 (UMLS CUI [1,2])
CL.9
Code List
Sample Storage
CL Item
Room Temperature (room temperature)
C1822393 (UMLS CUI-1)
(Comment:en)
CL Item
4 Degrees Celsius (4 degrees celsius)
(Comment:en)
CL Item
Frozen-dry Ice (frozen-dry ice)
(Comment:en)
CL Item
Frozen-ice Packs (frozen-ice packs)
(Comment:en)
CL Item
Fresh-wet Ice (fresh-wet ice)
(Comment:en)
CL Item
Minus 20 Degrees Celsius (minus 20)
(Comment:en)
CL Item
Minus 70 Degrees Celsius (minus 70)
(Comment:en)
CL Item
Frozen-liquid Nitrogen (liquid nitrogen)
C0260055 (UMLS CUI-1)
(Comment:en)
Item
Sample Condition
text
C1547869 (UMLS CUI [1])
CL.10
Code List
Sample Condition
CL Item
Useable (OK)
C1550137 (UMLS CUI-1)
(Comment:en)
CL Item
Damaged Or Unusable (damaged)
(Comment:en)
CL Item
No Specimen Received (missing)
(Comment:en)
CL Item
too old (too old)
(Comment:en)
CL Item
poor viability (poor viability)
(Comment:en)
CL Item
thawed (thawed)
(Comment:en)
CL Item
insufficient amount (insufficient amount)
(Comment:en)
CL Item
low blast count (low blast count)
(Comment:en)
CL Item
low tumor count (low tumor count)
(Comment:en)
CL Item
no positive tumor (no positive tumor)
(Comment:en)
CL Item
poor fixation (poor fixation)
CL Item
clotted (clotted)
CL Item
thawed, cold (thawed, cold)
CL Item
thawed, warm (thawed, warm)
CL Item
frozen (frozen)
Completed By
Item
Completed By (Print or Type Name)
text
C1550483 (UMLS CUI [1])
Form Original Complete Date
Item
Date Completed
date
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1549507 (UMLS CUI [1])
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
AmendedDataInd
Item
Amended data
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C1511726 (UMLS CUI [1,1])
C1691222 (UMLS CUI [1,2])
Patient'sName
Item
Patient?s Name
text
PatientHospitalNumber
Item
Patient Hospital Number
text
MainMemberInstitution/Affiliate
Item
Main Member Institution/Adjunct
text
ParticipatingGroupName
Item
Participating Group
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient No.
text
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