Information:
Error:
ID
25799
Description
Procurement Form - RF37 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE38528-2D40-4EF1-E034-0003BA12F5E7
Link
Keywords
Versions (2)
- 9/19/12 9/19/12 -
- 9/20/17 9/20/17 -
Uploaded on
September 20, 2017
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Procurement Form - RF37
No Instruction available.
- StudyEvent: Procurement Form - RF37
Similar models
No Instruction available.
- StudyEvent: Procurement Form - RF37
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Procurement Form - Rf37
C1709695 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
C0920316 (UMLS CUI-3)
C0370003 (UMLS CUI-2)
C0920316 (UMLS CUI-3)
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Study Identifier
Item
Study Identifier
text
C2826693 (UMLS CUI [1])
Site Identifier
Item
Site Identifier
text
C0018704 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Subject ID
Item
ID Number
text
C2348585 (UMLS CUI [1])
Cycle Number
Item
Cycle Number
text
C2045829 (UMLS CUI [1])
Date Specimen Obtained
Item
Date Specimen Obtained
date
C0370003 (UMLS CUI [1,1])
C1516698 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C1516698 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Specimen(s) obtained for donation to ACSB
Item
Specimen(s) obtained for donation to ACSB?
boolean
C0370003 (UMLS CUI [1,1])
C1515838 (UMLS CUI [1,2])
C0680854 (UMLS CUI [1,3])
C1515838 (UMLS CUI [1,2])
C0680854 (UMLS CUI [1,3])
Item
Types of specimens collected
integer
C0332307 (UMLS CUI [1,1])
C0370003 (UMLS CUI [1,2])
C0370003 (UMLS CUI [1,2])
CL Item
Serum (1)
CL Item
Plasma (2)
CL Item
PBMC (3)
CL Item
Whole Blood (4)
CL Item
Tissue (5)
CL Item
Other, Specify (6)
Item
ACSB site the specimen(s) shipped to
integer
C1515838 (UMLS CUI [1,1])
C0450429 (UMLS CUI [1,2])
C0450429 (UMLS CUI [1,2])
CL Item
GWU (1)
CL Item
UCLA (2)
CL Item
UCSF (3)
CL Item
OSU (4)
CL Item
SUNY/HSCB (5)
CL Item
Other, Specify (6)
Item
If specimens were not obtained for ACSB, please indicate reason
integer
C0370003 (UMLS CUI [1,1])
C1516698 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
C1516698 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
CL Item
Patient had previously donated specimens to ACSB. (1)
CL Item
Patient refused to give informed consent for ACSB specimen donation (2)
CL Item
Patient was not asked to consider ACSB specimen donation (3)
CL Item
Other, Specify (4)
Other,Specify
Item
Other, Specify
text
C0370003 (UMLS CUI [1,1])
C1516698 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
C1516698 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
Date Patient previously donated specimens to ACSB
Item
Patient previously donated specimens to ACSB, Indicate date
date
C0370003 (UMLS CUI [1,1])
C0680854 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
C0680854 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C1515838 (UMLS CUI [2])
StudyCoordinator'sName
Item
Study Coordinator's Name
text
C1547383 (UMLS CUI [1,1])
C1710220 (UMLS CUI [1,2])
C1710220 (UMLS CUI [1,2])
PhoneNumber
Item
Phone Number
text
C1515258 (UMLS CUI [1,1])
C1710220 (UMLS CUI [1,2])
C1710220 (UMLS CUI [1,2])
E-mailAddress
Item
E-mail Address
text
C1705961 (UMLS CUI [1,1])
C1710220 (UMLS CUI [1,2])
C1710220 (UMLS CUI [1,2])