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2876

Beschreibung

CALGB: 90202 SPECIMEN ROUTING FORM (Serum) Zoledronate in Preventing Skeletal (Bone)-Related Events in Patients Who Are Receiving Androgen Deprivation Therapy For Prostate Cancer and Bone Metastases Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B4605919-9C2B-050C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B4605919-9C2B-050C-E034-0003BA12F5E7

Stichworte

  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
  3. 09.01.15 09.01.15 - Martin Dugas
  4. 29.06.15 29.06.15 -
Hochgeladen am

19. September 2012

DOI

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    Prostate Cancer NCT00079001 Pathology - CALGB: 90202 SPECIMEN ROUTING FORM (SERUM) - 2075901v3.0

    To complete this section, see instructions.

    1. StudyEvent: CALGB: 90202 SPECIMEN ROUTING FORM (SERUM)
      1. To complete this section, see instructions.
    Ccrr Module For Calgb: 90202 Specimen Routing Form Plasma
    Beschreibung

    Ccrr Module For Calgb: 90202 Specimen Routing Form Plasma

    CALGB Form
    Beschreibung

    CALGBForm

    Datentyp

    text

    CALGB Study No
    Beschreibung

    ProtocolCALGBIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25442
    UMLS 2011AA Property
    C1516238
    CALGB Patient ID
    Beschreibung

    PatientCALGBIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25442
    UMLS 2011AA Property
    C1516238
    Amended data
    Beschreibung

    DataAmendedInd-3

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Patient?s Name
    Beschreibung

    PatientName

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Hospital Number
    Beschreibung

    PatientMedicalRecordNumber

    Datentyp

    text

    Main Member Institution/Adjunct
    Beschreibung

    CombinedInstitutionName

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Participating Group
    Beschreibung

    ParticipatingGroupName

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25608
    UMLS 2011AA ObjectClass
    C0679823
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Protocol No.
    Beschreibung

    ProtocolParticipatingIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Patient No.
    Beschreibung

    PatientParticipatingIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    To Be Completed By Submitting Institution
    Beschreibung

    To Be Completed By Submitting Institution

    Sample No.
    Beschreibung

    SpecimenCollectionSamplingNumber

    Datentyp

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25452
    Date of Collection of Sample for Analysis
    Beschreibung

    SpecimenLaboratoryProcedureCollectionDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25453
    UMLS 2011AA Property
    C1516698
    NCI Thesaurus Property
    C25294
    UMLS 2011AA Property
    C0022885
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    Does specimen accompany this form?
    Beschreibung

    SpecimenFormSubmittedInd-2

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C19464
    UMLS 2011AA Property
    C0376315
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    Specimen Period Collected Time
    Beschreibung

    SpecimenPeriodCollectedTime

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    NCI Thesaurus Property
    C25452
    NCI Thesaurus ValueDomain
    C25207
    UMLS 2011AA ValueDomain
    C0040223
    NCI Thesaurus ValueDomain
    C25452
    Specify reason
    Beschreibung

    SpecimenNotSubmittedReason

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    No specify
    Beschreibung

    SpecimenNotSubmittedSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    Unnamed Module 3
    Beschreibung

    Unnamed Module 3

    Number of tubes submitted
    Beschreibung

    TubeSpecimenSubmittedNumber

    Datentyp

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C41277
    UMLS 2011AA ObjectClass
    C1561954
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    LabTrak sample ID
    Beschreibung

    LabSpecimenIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C37984
    UMLS 2011AA ObjectClass
    C0022877
    NCI Thesaurus Property
    C19157
    UMLS 2011AA Property
    C0370003
    Shipment date
    Beschreibung

    LaboratoryProcedureDeliveryDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    NCI Thesaurus Property
    C61560
    Responsible Person Name
    Beschreibung

    ResponsiblePersonName

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Responsible Person Phone Number
    Beschreibung

    ResponsiblePersonPhoneNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    LabTrak shipment ID
    Beschreibung

    LabTransportIdentifierNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C37984
    UMLS 2011AA ObjectClass
    C0022877
    NCI Thesaurus Property
    C61560

    Ähnliche Modelle

    To complete this section, see instructions.

    1. StudyEvent: CALGB: 90202 SPECIMEN ROUTING FORM (SERUM)
      1. To complete this section, see instructions.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Ccrr Module For Calgb: 90202 Specimen Routing Form Plasma
    CALGBForm
    Item
    CALGB Form
    text
    ProtocolCALGBIdentifierNumber
    Item
    CALGB Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25442 (NCI Thesaurus Property)
    C1516238 (UMLS 2011AA Property)
    PatientCALGBIdentifierNumber
    Item
    CALGB Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25442 (NCI Thesaurus Property)
    C1516238 (UMLS 2011AA Property)
    Item
    Amended data
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    Code List
    Amended data
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    PatientName
    Item
    Patient?s Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientMedicalRecordNumber
    Item
    Patient Hospital Number
    text
    CombinedInstitutionName
    Item
    Main Member Institution/Adjunct
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    ParticipatingGroupName
    Item
    Participating Group
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Group Protocol No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientParticipatingIdentifierNumber
    Item
    Participating Group Patient No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Item Group
    To Be Completed By Submitting Institution
    SpecimenCollectionSamplingNumber
    Item
    Sample No.
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus Property)
    SpecimenLaboratoryProcedureCollectionDate
    Item
    Date of Collection of Sample for Analysis
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25453 (NCI Thesaurus Property)
    C1516698 (UMLS 2011AA Property)
    C25294 (NCI Thesaurus Property)
    C0022885 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    Item
    Does specimen accompany this form?
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C19464 (NCI Thesaurus Property)
    C0376315 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    Code List
    Does specimen accompany this form?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Specimen Period Collected Time
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    C25452 (NCI Thesaurus Property)
    C25207 (NCI Thesaurus ValueDomain)
    C0040223 (UMLS 2011AA ValueDomain)
    C25452 (NCI Thesaurus ValueDomain)
    Code List
    Specimen Period Collected Time
    CL Item
    12 Months After Protocol Therapy (12 months)
    CL Item
    6 Months After Protocol Therapy (6 months)
    CL Item
    At Disease Progression (At disease progression)
    CL Item
    Baseline (Baseline)
    C25213 (NCI Thesaurus)
    C1442488 (UMLS 2011AA)
    Item
    Specify reason
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    Code List
    Specify reason
    CL Item
    Institution Error (Institution error)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Patient Refusal (Patient refusal)
    CL Item
    Sample Lost Or Destroyed (Sample lost or destroyed)
    SpecimenNotSubmittedSpecify
    Item
    No specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    Item Group
    Unnamed Module 3
    TubeSpecimenSubmittedNumber
    Item
    Number of tubes submitted
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C41277 (NCI Thesaurus ObjectClass)
    C1561954 (UMLS 2011AA ObjectClass)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    LabSpecimenIdentifierNumber
    Item
    LabTrak sample ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C37984 (NCI Thesaurus ObjectClass)
    C0022877 (UMLS 2011AA ObjectClass)
    C19157 (NCI Thesaurus Property)
    C0370003 (UMLS 2011AA Property)
    LaboratoryProcedureDeliveryDate
    Item
    Shipment date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C61560 (NCI Thesaurus Property)
    ResponsiblePersonName
    Item
    Responsible Person Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ResponsiblePersonPhoneNumber
    Item
    Responsible Person Phone Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    LabTransportIdentifierNumber
    Item
    LabTrak shipment ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C37984 (NCI Thesaurus ObjectClass)
    C0022877 (UMLS 2011AA ObjectClass)
    C61560 (NCI Thesaurus Property)

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