ID

2838

Beskrivning

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

Länk

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

Nyckelord

Versioner (4)
  1. 2012-09-19 2012-09-19 -
  2. 2014-08-08 2014-08-08 - Martin Dugas
  3. 2015-06-02 2015-06-02 -
  4. 2015-06-03 2015-06-03 -
Uppladdad den

19 september 2012

DOI

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Licens

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

Engelsk

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 Formulär  
Unnamed1
Beskrivning

Unnamed1

RTOG Study
Beskrivning

RTOGStudy

Datatyp

text

Case #
Beskrivning

Case#

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Institution
Beskrivning

Institution

Datatyp

text

Institution No.
Beskrivning

InstitutionNo.

Datatyp

text

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

Patient'sName

Datatyp

text

Patient's I.D. No.
Beskrivning

Patient'sI.D.No.

Datatyp

text

Unnamed3
Beskrivning

Unnamed3

Unnamed4
Beskrivning

Unnamed4

TYPE (pathology submission)
Beskrivning

TYPE(pathologysubmission)

Datatyp

text

PROCEDURE DATE
Beskrivning

PROCEDUREDATE

Datatyp

date

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

SITEOFMATERIAL

Datatyp

text

H&E Stained Slides
Beskrivning

H&EStainedSlides

Datatyp

double

Unstained Slides
Beskrivning

UnstainedSlides

Datatyp

double

Blocks
Beskrivning

Blocks

Datatyp

double

PATHOLOGY ACCESSION #
Beskrivning

PATHOLOGYACCESSION#

Datatyp

text

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

RTOGCalendarduedate

Datatyp

date

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

Unnamed5

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

REQUIREDENCLOSURES

Datatyp

text

Patient consents to:
Beskrivning

Patientconsentsto:

Datatyp

text

SUBMITTED BY
Beskrivning

PersonSpecimenSubmittedName

Datatyp

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
Beskrivning

TELEPHONENO

Datatyp

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
Beskrivning

Ccrr Module For Radiation Therapy Oncology Group Pathology Submission Form

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Similar models

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 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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