Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice....

1 Formulaires

StudyEvent: CALGB 90203: Paraffin Tissue Submission Form
1. Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice....

Name

Type

Description | Question | Decode (Coded Value)

Type de données

Alias

Header Module

Item Group

Ccrr Module For Calgb 90202: Prostate Specific Antigen Form

CALGBFormIdentifierNumber

Item

CALGB Form (C-714)

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus ObjectClass)
C1516238 (UMLS 2011AA ObjectClass)

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)

SpecimenCollectedDate

Item

Date Specimen collected

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

DataAmendedInd-3

Item

Are data amended

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)

CL.1

Code List

Are data amended

CL Item

Yes (yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

PatientInitialsName

Item

Patient Initials (Last, First Middle)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)

PatientMedicalRecordNumber

Item

Patient Hospital No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (UMLS 2011AA Property)

CombinedInstitutionName

Item

Institution/Affiliate

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 Study 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 ID

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)

Module 2

Item Group

Unnamed3

SpecimenCollectionPeriodType

Item

Timing of material collection (Mark one)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

CL.2

Code List

Timing of material collection (Mark one)

CL Item

Biopsy (Biopsy)

C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)

CL Item

Prostatectomy (Prostatectomy)

SpecimenSubmittedType

Item

Specimen Type

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)

CL.12

Code List

Specimen Type

CL Item

Cores From Prostate Tumor Tissue (Cores from prostate tumor tissue)

CL Item

Cores From Normal Prostate Tissue (Cores from normal prostate tissue)

SpecimenPrimaryMalignantNeoplasmProstateGlandSubmissionType

Item

Representative primary tumor from prostate

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C12410 (NCI Thesaurus Property)
C0033572 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.4

Code List

Representative primary tumor from prostate

CL Item

Tissue, Paraffin (Paraffin block)

C19597 (NCI Thesaurus)
C1519524 (UMLS 2011AA)

CL Item

Unstained Specimen (Unstained slide)

C62755 (NCI Thesaurus)
C1883469 (UMLS 2011AA)

SpecimenPrimaryMalignantNeoplasmSeminalVesicleSubmissionType

Item

Representative primary tumor from seminal vesicle

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C12787 (NCI Thesaurus Property)
C0036628 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.5

Code List

Representative primary tumor from seminal vesicle

CL Item

Tissue, Paraffin (Paraffin block)

C19597 (NCI Thesaurus)
C1519524 (UMLS 2011AA)

CL Item

Unstained Specimen (Unstained slide)

C62755 (NCI Thesaurus)
C1883469 (UMLS 2011AA)

SpecimenPrimaryMalignantNeoplasmLymphNodeSubmissionType

Item

Representative primary tumor from lymph node

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C12745 (NCI Thesaurus Property)
C0024204 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.6

Code List

Representative primary tumor from lymph node

CL Item

Tissue, Paraffin (Paraffin block)

C19597 (NCI Thesaurus)
C1519524 (UMLS 2011AA)

CL Item

Unstained Specimen (Unstained slide)

C62755 (NCI Thesaurus)
C1883469 (UMLS 2011AA)

SpecimenSubmittedCount

Item

Number of specimens submitted

double

C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)

SpecimenLabSubmittedDate

Item

Date shipped (mm dd yyyy)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)

SpecimenBlockIdentifier

Item

Block number/letter

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25436 (NCI Thesaurus Property)
C1533157 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

SpecimenNotSubmittedReason

Item

If none submitted, 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)

CL.13

Code List

If none submitted, specify reason

CL Item

Institution Error (Institution error)

CL Item

Patient Refusal (Patient refusal)

CL Item

Patient Unable To Submit Sample (Patient unable to submit sample)

CL Item

Sample Lost Or Destroyed (Sample lost or destroyed)

CL Item

Insufficient/scant Sample (Insufficient/scant sample)

CL Item

Instituition Won't Release (Instituition won't release)

CL Item

Sample Not Required (Sample not required)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

SpecimenAccessionNumber

Item

Accession Number

double

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25402 (NCI Thesaurus Property)
C1510755 (UMLS 2011AA Property)

Module 4

Item Group

Module 4

SubmissionInstitutionSpecimenBlocksReturnRequestInd-2

Item

Is institution requesting return of blocks

text

C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus ObjectClass)
C1515022 (UMLS 2011AA ObjectClass)
C25436 (NCI Thesaurus Property)
C1533157 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C48312 (NCI Thesaurus Property)
C1272683 (UMLS 2011AA Property)
C71900 (NCI Thesaurus Property)
C0332156 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.8

Code List

Is institution requesting return of blocks

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

SubmissionInstitutionSpecimenBlocksReturnRequestDate

Item

Date of return

date

C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus ObjectClass)
C1515022 (UMLS 2011AA ObjectClass)
C25436 (NCI Thesaurus Property)
C1533157 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C48312 (NCI Thesaurus Property)
C1272683 (UMLS 2011AA Property)
C71900 (NCI Thesaurus Property)
C0332156 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

PersonTissueMicroarrayClinicalTrialRegistrationInd-2

Item

Is the patient registered to TMA substudy 150413

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
C19922 (NCI Thesaurus Property)
C1519522 (UMLS 2011AA Property)
C71104 (NCI Thesaurus Property)
C0008976 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.9

Code List

Is the patient registered to TMA substudy 150413

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

SpecimenTissueMicroarrayProstatectomySubmissionInd-2

Item

Are TMA samples being submitted at prostatectomy (If yes,)

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19922 (NCI Thesaurus Property)
C1519522 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C15307 (NCI Thesaurus Property)
C0033573 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.10

Code List

Are TMA samples being submitted at prostatectomy (If yes,)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

SpecimenTissueMicroarrayProstatectomySubmissionType

Item

Sample type (Mark one with an X)

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C19922 (NCI Thesaurus Property)
C1519522 (UMLS 2011AA Property)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C15307 (NCI Thesaurus Property)
C0033573 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.11

Code List

Sample type (Mark one with an X)

CL Item

Core Biopsy (Cores)

C15680 (NCI Thesaurus)
C1318309 (UMLS 2011AA)

CL Item

Paraffin Blocks (Parraffin block)

C25436 (NCI Thesaurus)
C1533157 (UMLS 2011AA)
C727 (NCI Thesaurus)
C0030415 (UMLS 2011AA)

Module 5

Item Group

Unnamed3

SpecimenSubmittedType

Item

Specimen Type

text

CL.12

Code List

Specimen Type

CL Item

Cores From Prostate Tumor Tissue (Cores from prostate tumor tissue)

CL Item

Cores From Normal Prostate Tissue (Cores from normal prostate tissue)

SpecimenSubmittedCount

Item

Number of specimens submitted

double

SpecimenBlockIdentifier

Item

Block number/letter

text

SpecimenNotSubmittedReason

Item

If none submitted, specify reason

text

CL.13

Code List

If none submitted, specify reason

CL Item

Institution Error (Institution error)

CL Item

Patient Refusal (Patient refusal)

CL Item

Patient Unable To Submit Sample (Patient unable to submit sample)

CL Item

Sample Lost Or Destroyed (Sample lost or destroyed)

CL Item

Insufficient/scant Sample (Insufficient/scant sample)

CL Item

Instituition Won't Release (Instituition won't release)

CL Item

Sample Not Required (Sample not required)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

Shipping Information

Item Group

Shipping Information

SpecimenSubmissionInstitutionName

Item

Submitting Institution

text

C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25694 (NCI Thesaurus ObjectClass)
C1515022 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)

CentralLaboratoryContactPersonName

Item

Contact Person Name

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C0205099 (NCI Metathesaurus ObjectClass)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)

CentralLaboratoryContactTelephoneNumber

Item

Contact Phone Number

text

C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C64207 (NCI Thesaurus ObjectClass)
C1880016 (UMLS 2011AA ObjectClass)
C25395 (NCI Thesaurus Property)
C0039457 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)

CentralLaboratoryContactPersonEmailAddressText

Item

Contact Person E-Mail

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C0205099 (NCI Metathesaurus ObjectClass)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS 2011AA Property)
C25170 (NCI Thesaurus ValueDomain)
C0013849 (UMLS 2011AA ValueDomain)

LabTransportIdentifierNumber

Item

LabTrak shipment ID (LabTrak use is required of all CALGB institutions. Access LabTrak users application via calgb.org member website. First time users must contact CALGB Help Desk at 1-877-44CALGB to set up LabTrak account.)

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)

SpecimenLabSubmittedDate

Item

Date shipped (mm dd yyyy)

date

Comments

Item Group

Footer Module Pg2

ResearchCommentsText

Item

Comments

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)

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