ID

2838

Beschreibung

Radiation Therapy Oncology Group Pathology Submission Form Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CFF7E-9D16-2C2B-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CFF7E-9D16-2C2B-E034-080020C9C0E0

Stichworte

Versionen (4)
  1. 19.09.12 19.09.12 -
  2. 08.08.14 08.08.14 - Martin Dugas
  3. 02.06.15 02.06.15 -
  4. 03.06.15 03.06.15 -
Hochgeladen am

19. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT00023829 Transmittal - Radiation Therapy Oncology Group Pathology Submission Form - 2039934v3.0

Englisch

INSTRUCTIONS This form must be completed and mailed with the pathology specimens whenever slides or blocks are sent to LDS Hospital. Please see protocol for list of required materials.

1 Formulare  
Unnamed1
Beschreibung

Unnamed1

RTOG Study
Beschreibung

RTOGStudy

Datentyp

text

Case #
Beschreibung

Case#

Datentyp

text

Unnamed2
Beschreibung

Unnamed2

Institution
Beschreibung

Institution

Datentyp

text

Institution No.
Beschreibung

InstitutionNo.

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Patient's I.D. No.
Beschreibung

Patient'sI.D.No.

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Unnamed4
Beschreibung

Unnamed4

TYPE (pathology submission)
Beschreibung

TYPE(pathologysubmission)

Datentyp

text

PROCEDURE DATE
Beschreibung

PROCEDUREDATE

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
SITE OF MATERIAL (NUMBER OF SPECIMENS)
Beschreibung

SITEOFMATERIAL

Datentyp

text

H&E Stained Slides
Beschreibung

H&EStainedSlides

Datentyp

double

Unstained Slides
Beschreibung

UnstainedSlides

Datentyp

double

Blocks
Beschreibung

Blocks

Datentyp

double

PATHOLOGY ACCESSION #
Beschreibung

PATHOLOGYACCESSION#

Datentyp

text

RTOG Calendar due date ("P1, P2")
Beschreibung

RTOGCalendarduedate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed5
Beschreibung

Unnamed5

REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
Beschreibung

REQUIREDENCLOSURES

Datentyp

text

Patient consents to:
Beschreibung

Patientconsentsto:

Datentyp

text

SUBMITTED BY
Beschreibung

PersonSpecimenSubmittedName

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
TELEPHONE NO
Beschreibung

TELEPHONENO

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form
Beschreibung

Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form

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Ähnliche Modelle

INSTRUCTIONS This form must be completed and mailed with the pathology specimens whenever slides or blocks are sent to LDS Hospital. Please see protocol for list of required materials.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
Item Group
Unnamed2
Institution
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
Patient'sI.D.No.
Item
Patient's I.D. No.
text
Item Group
Unnamed3
Item Group
Unnamed4
Item
TYPE (pathology submission)
text
CL.1
Code List
TYPE (pathology submission)
CL Item
Pre-treatment Bx (Pre-treatment Bx)
CL Item
Surgical Treatment (Surgical treatment)
CL Item
Post-treatment Bx (Post-treatment Bx)
CL Item
Autopsy (Autopsy)
C25153 (NCI Thesaurus)
C0004398 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PROCEDUREDATE
Item
PROCEDURE DATE
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SITEOFMATERIAL
Item
SITE OF MATERIAL (NUMBER OF SPECIMENS)
text
H&EStainedSlides
Item
H&E Stained Slides
double
UnstainedSlides
Item
Unstained Slides
double
Blocks
Item
Blocks
double
PATHOLOGYACCESSION#
Item
PATHOLOGY ACCESSION #
text
RTOGCalendarduedate
Item
RTOG Calendar due date ("P1, P2")
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Unnamed5
Item
REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
text
CL.2
Code List
REQUIRED ENCLOSURES (Check all that apply and submit with patient study consent form.)
CL Item
Pathology Report(s) (Pathology Report(s))
CL Item
Blocks/slides (Blocks/Slides)
CL Item
This Submission Form (This Submission Form)
CL Item
Patient Consent (Patient consent)
Item
Patient consents to:
text
CL.3
Code List
Patient consents to:
CL Item
Current Research As Specified In The Protocol (Current research as specified in the protocol)
CL Item
Future Research Using Tissue Bank Samples (Future research using Tissue Bank samples)
CL Item
Being Contacted About Future Research (Being contacted about future research)
PersonSpecimenSubmittedName
Item
SUBMITTED BY
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
TELEPHONENO
Item
TELEPHONE NO
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form
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