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ID
2810
Description
Procurement Form - RF37 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=CCE38528-2D40-4EF1-E034-0003BA12F5E7
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- 9/19/12 9/19/12 -
- 9/20/17 9/20/17 -
Uploaded on
September 19, 2012
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License
Creative Commons BY-NC 3.0 Legacy
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Sarcoma, Kaposi xxx On-Study - Procurement Form - RF37 - 2267179v3.0
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
PatientInitials
Item
Patient Initials
text
Study#
Item
Study#
text
Site#
Item
Site#
text
ID#
Item
ID#
text
Cycle#
Item
Cycle #
text
DateSpecimenObtained
Item
Date Specimen Obtained
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Serum (Serum)
CL Item
Plasma (Plasma)
CL Item
PBMC (PBMC)
CL Item
Whole Blood (Whole Blood)
CL Item
Tissue (Tissue)
CL Item
Other, Specify (Other, Specify)
CL Item
GWU (GWU)
CL Item
UCLA (UCLA)
CL Item
UCSF (UCSF)
CL Item
OSU (OSU)
CL Item
SUNY/HSCB (SUNY/HSCB)
CL Item
Other, Specify (Other, Specify)
Item
If specimens were not obtained for ACSB, please indicate reason
text
CL Item
Patient had previously donated specimens to ACSB. (Patient had previously donated specimens to ACSB.)
CL Item
Patient refused to give informed consent for ACSB specimen donation (Patient refused to give informed consent for ACSB specimen donation)
CL Item
Patient was not asked to consider ACSB specimen donation (Patient was not asked to consider ACSB specimen donation)
CL Item
Other, Specify (Other, Specify)
PatientpreviouslydonatedspecimenstoACSB,Indicatedate
Item
Patient previously donated specimens to ACSB, Indicate date
text
Other,Specify
Item
Other, Specify
text
StudyCoordinator'sName
Item
Study Coordinator's Name
text
PhoneNumber
Item
Phone Number
text
E-mailAddress
Item
E-mail Address
text