ID

24232

Description

AMC-059 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Kaposi's Sarcoma NCT00686842 Pathology - AMC-059 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) - 2932913v1.0 PTC299 in Treating Patients With HIV-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=71583731-B0E0-1194-E040-BB89AD437269

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=71583731-B0E0-1194-E040-BB89AD437269

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 7/27/17 7/27/17 - Martin Dugas
Uploaded on

July 27, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Kaposi Sarcoma PTC299 NCT00686842 AMC-059

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-059 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

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1]
C0947611
Study Coordinator's name
Description

Study Coordinator

Data type

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

Email

Data type

text

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

Organization Phone Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus Property
C25395
NCI Thesaurus ObjectClass
C19711
UMLS CUI [1]
C0039457
Specimen Procurement
Description

Specimen Procurement

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

Specimen donation

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1]
C0080231
Specimen Type (check all that apply)
Description

Specimen Type

Data type

text

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

Specimen Cell Source

Data type

text

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

ACSR site

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1,1]
C1515830
UMLS CUI [1,2]
C1524049
Other, specify
Description

ACSR site

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass-2
C19707
NCI Thesaurus Property
C54153
UMLS CUI [1,1]
C1515830
UMLS CUI [1,2]
C1524049
If specimens were not obtained for ACSR, please indicate reason
Description

reason not submitted

Data type

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, specify
Description

reason not submitted

Data type

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
Date Specimen Obtained (for previously donated specimens)
Description

Specimen collection date

Data type

date

Measurement units
  • mm/dd/yyyy
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25452
NCI Thesaurus Property-2
C25275
UMLS CUI [1]
C1302413
mm/dd/yyyy
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-059 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
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])
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (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])
Organization Phone Number
Item
Phone number
text
C25337 (NCI Thesaurus ValueDomain)
C25395 (NCI Thesaurus Property)
C19711 (NCI Thesaurus ObjectClass)
C0039457 (UMLS CUI [1])
Item Group
Specimen Procurement
C0370003 (UMLS CUI-1)
C1709695 (UMLS CUI-2)
Specimen 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)
C0080231 (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
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 Cell Source
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C12508 (NCI Thesaurus Property)
C25683 (NCI Thesaurus Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS CUI [1,1])
C0449416 (UMLS CUI [1,2])
Item
ACSR site the specimen(s) shipped to
integer
C25284 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C1515830 (UMLS CUI [1,1])
C1524049 (UMLS CUI [1,2])
CL.3
Code List
ACSR site the specimen(s) shipped to
CL Item
GWU (1)
CL Item
UCLA (2)
CL Item
UCSF (3)
CL Item
OSU (4)
CL Item
SUNY/HSCB (5)
CL Item
JHU (6)
CL Item
Other (7)
ACSR site
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C19707 (NCI Thesaurus ObjectClass-2)
C54153 (NCI Thesaurus Property)
C1515830 (UMLS CUI [1,1])
C1524049 (UMLS CUI [1,2])
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 Was Not Asked To Consider ACSR Specimen Donation (not asked)
C1548670 (UMLS CUI-1)
(Comment:en)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused)
C1705116 (UMLS CUI-1)
(Comment:en)
CL Item
Patient Had Previously Donated Specimen To Acsr (previous donation)
C0013018 (UMLS CUI-1)
C0332152 (UMLS CUI-2)
(Comment:en)
CL Item
Other (other)
C0205394 (UMLS CUI-1)
(Comment:en)
reason not submitted
Item
Other, 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
Date Specimen Obtained (for previously donated specimens)
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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