ID

3195

Descripción

Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Pathology Submission Form Radiation Therapy in Treating Patients With Stage II Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CF5748-0C1F-4085-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CF5748-0C1F-4085-E044-0003BA3F9857

Palabras clave

Versiones (4)
  1. 19/9/12 19/9/12 -
  2. 8/8/14 8/8/14 - Martin Dugas
  3. 2/6/15 2/6/15 -
  4. 3/6/15 3/6/15 -
Subido en

19 de septiembre de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT00033631 Transmittal - Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Pathology Submission Form - 2476196v1.0

Inglés

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 formularios  
Unnamed1
Descripción

Unnamed1

RTOG Study
Descripción

RTOGStudy

Tipo de datos

text

Case #
Descripción

Case#

Tipo de datos

text

Unnamed2
Descripción

Unnamed2

Institution
Descripción

Institution

Tipo de datos

text

Institution No.
Descripción

InstitutionNo.

Tipo de datos

text

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

Patient'sName

Tipo de datos

text

Patient's I.D. No.
Descripción

Patient'sI.D.No.

Tipo de datos

text

Unnamed3
Descripción

Unnamed3

Unnamed4
Descripción

Unnamed4

TYPE (pathology submission)
Descripción

TYPE(pathologysubmission)

Tipo de datos

text

PROCEDURE DATE
Descripción

PROCEDUREDATE

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
SITE OF MATERIAL
Descripción

SITEOFMATERIAL

Tipo de datos

text

H&E Stained Slides (NUMBER OF SPECIMENS)
Descripción

H&EStainedSlides

Tipo de datos

double

Unstained Slides (NUMBER OF SPECIMENS)
Descripción

UnstainedSlides

Tipo de datos

double

Blocks (NUMBER OF SPECIMENS)
Descripción

Blocks

Tipo de datos

double

PATHOLOGY ACCESSION #
Descripción

PATHOLOGYACCESSION#

Tipo de datos

text

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

RTOGCalendarduedate

Tipo de datos

date

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

Unnamed5

REQUIRED ENCLOSURES
Descripción

REQUIREDENCLOSURES

Tipo de datos

text

Patient consents to: (Check all that apply and submit with patient study consent form.)
Descripción

Patientconsentsto:

Tipo de datos

text

SUBMITTED BY
Descripción

PersonSpecimenSubmittedName

Tipo de datos

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
Descripción

TELEPHONENO

Tipo de datos

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
Descripción

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 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
text
H&EStainedSlides
Item
H&E Stained Slides (NUMBER OF SPECIMENS)
double
UnstainedSlides
Item
Unstained Slides (NUMBER OF SPECIMENS)
double
Blocks
Item
Blocks (NUMBER OF SPECIMENS)
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
text
CL.2
Code List
REQUIRED ENCLOSURES
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: (Check all that apply and submit with patient study consent form.)
text
CL.3
Code List
Patient consents to: (Check all that apply and submit with patient study consent form.)
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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