ID

2502

Beschreibung

AMC-064 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Study of Blood and Tissue Samples From Patients With Aggressive Non-Hodgkin B-Cell Lymphoma or Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7C993962-2829-EDFE-E040-BB89AD43562B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7C993962-2829-EDFE-E040-BB89AD43562B

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 28.08.17 28.08.17 -
Hochgeladen am

19. September 2012

DOI

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Lymphoma NCT00981097 Pathology - AMC-064 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) - 2982989v1.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: AMC-064 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

Visit number
Beschreibung

HospitalAdmissionOrdinalNumber

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16696
UMLS 2011AA ObjectClass
C0019994
NCI Thesaurus Property
C25385
UMLS 2011AA Property
C0809949
Unnamed2
Beschreibung

Unnamed2

Specimen(s) obtained for donation to ACSR
Beschreibung

AIDSMalignancyConsortiumSpecimenProcurementInd-2

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C54153
UMLS 2011AA Property
C1709695
Specimen Type (check all that apply)
Beschreibung

SpecimenSubmittedType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Other specify
Beschreibung

SpecimenCellSourceSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C12508
UMLS 2011AA Property
C0007634
NCI Thesaurus Property
C25683
UMLS 2011AA Property
C0449416
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
ACSR site the specimen(s) shipped to
Beschreibung

AIDSMalignancyConsortiumSpecimenProcurementType

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C54153
UMLS 2011AA Property
C1709695
Other, specify
Beschreibung

AIDSMalignancyConsortiumSpecimenProcurementSpecify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C54153
UMLS 2011AA Property
C1709695
If specimens were not obtained for ACSR, please indicate reason
Beschreibung

AIDSMalignancyConsortiumSpecimenNotSubmittedReason

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Beschreibung

AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
Beschreibung

SpecimenCollectedDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25452
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
Beschreibung

SpecimenCollectedDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25452
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Study Coordinator
Beschreibung

Study Coordinator

Study Coordinator's name
Beschreibung

AIDSMalignancyConsortiumPersonStudyCoordinatorName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C19707
UMLS 2011AA ObjectClass
C1515830
NCI Thesaurus Property
C51880
UMLS 2011AA Property
C1710220
E-mail
Beschreibung

ResponsiblePersonE-mailAddressText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C42775
UMLS 2011AA Property
C1705961
Phone Number (xxx-xxx-xxxx)
Beschreibung

OrganizationPhoneNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus ObjectClass
C19711
UMLS 2011AA ObjectClass
C1522486
Comments
Beschreibung

Comments

Comments
Beschreibung

ResearchCommentsText

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: AMC-064 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
HospitalAdmissionOrdinalNumber
Item
Visit number
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
Item Group
Unnamed2
Item
Specimen(s) obtained for donation to ACSR
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C54153 (NCI Thesaurus Property)
C1709695 (UMLS 2011AA Property)
CL.1
Code List
Specimen(s) obtained for donation to ACSR
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Specimen Type (check all that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
CL.2
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
C13325 (NCI Thesaurus)
C0229671 (UMLS 2011AA)
C13325 (NCI Thesaurus)
C0229671 (UMLS 2011AA)
CL Item
Plasma (Plasma)
C13356 (NCI Thesaurus)
C0032105 (UMLS 2011AA)
C13356 (NCI Thesaurus)
C0032105 (UMLS 2011AA)
CL Item
Pbmc (peripheral Blood Mononuclear Cells) (PBMC)
CL Item
Peripheral Blood (Blood)
C0229664 (NCI Metathesaurus)
C0229664 (NCI Metathesaurus)
CL Item
Tissue (Tissue)
C12801 (NCI Thesaurus)
C0040300 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
SpecimenCellSourceSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C25683 (NCI Thesaurus Property)
C0449416 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
Item
ACSR site the specimen(s) shipped to
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C54153 (NCI Thesaurus Property)
C1709695 (UMLS 2011AA Property)
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)
AIDSMalignancyConsortiumSpecimenProcurementSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C54153 (NCI Thesaurus Property)
C1709695 (UMLS 2011AA Property)
Item
If specimens were not obtained for ACSR, please indicate reason
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
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)
AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify
Item
Other, specify
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item Group
Study Coordinator
AIDSMalignancyConsortiumPersonStudyCoordinatorName
Item
Study Coordinator's name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19707 (NCI Thesaurus ObjectClass)
C1515830 (UMLS 2011AA ObjectClass)
C51880 (NCI Thesaurus Property)
C1710220 (UMLS 2011AA Property)
ResponsiblePersonE-mailAddressText
Item
E-mail
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS 2011AA Property)
OrganizationPhoneNumber
Item
Phone Number (xxx-xxx-xxxx)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C19711 (NCI Thesaurus ObjectClass)
C1522486 (UMLS 2011AA ObjectClass)
Item Group
Comments
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
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