ID

42743

Description

S0100 SPECIMEN SUBMISSION FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB420C1-7F40-419F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB420C1-7F40-419F-E034-0003BA12F5E7

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 8/21/17 8/21/17 -
  3. 9/17/21 9/17/21 -
Uploaded on

September 17, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Leukemia null Pathology - S0100 SPECIMEN SUBMISSION FORM - 2070809v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Specimen
Description

Specimen

Alias
UMLS CUI-1
C0370003
Type of Specimen
Description

Type of Specimen

Data type

integer

Alias
UMLS CUI [1]
C0456204
Tissue, specify site
Description

Tissue

Data type

text

Alias
UMLS CUI [1,1]
C0040300
UMLS CUI [1,2]
C1515974
Tissue state
Description

Tissue state

Data type

integer

Alias
UMLS CUI [1,1]
C0040300
UMLS CUI [1,2]
C0332307
Slides, type and number
Description

number

Data type

text

Alias
UMLS CUI [1,1]
C1705201
UMLS CUI [1,2]
C0237753
UMLS CUI [2,1]
C1705201
UMLS CUI [2,2]
C0332307
Karotype(s), number
Description

Karyotype

Data type

text

Alias
UMLS CUI [1,1]
C1261273
UMLS CUI [1,2]
C0237753
Date specimen collected
Description

Specimen Collection Date

Data type

date

Alias
UMLS CUI [1]
C1302413
Time specimen collected
Description

Specimen Collection Time

Data type

time

Alias
UMLS CUI [1]
C4064021
Other (typeofspecimen) , specify
Description

Other

Data type

text

Alias
UMLS CUI [1,1]
C0456204
UMLS CUI [1,2]
C0205394
Reasons For Specimen Submission
Description

Reasons For Specimen Submission

Alias
UMLS CUI-1
C0370003
UMLS CUI-2
C0392360
UMLS CUI-3
C1515023
Status
Description

Clinical Status Specimen

Data type

integer

Alias
UMLS CUI [1,1]
C0456204
UMLS CUI [1,2]
C0449438
Other specimen, specify
Description

Other specimen,specify

Data type

text

Alias
UMLS CUI [1,1]
C0456204
UMLS CUI [1,2]
C0205394
Completed By
Description

Completed By

Data type

text

Alias
UMLS CUI [1]
C1550483
Date form completed
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1115437
Notes from submitting institution
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Central Laboratory
Description

Central Laboratory

Alias
UMLS CUI-1
C1880016
Central laboratory identification number
Description

Central laboratory identification number

Data type

text

Alias
UMLS CUI [1,1]
C1880016
UMLS CUI [1,2]
C0600091
Date specimen received
Description

Date specimen received

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2585542
Completed By
Description

Completed By

Data type

text

Alias
UMLS CUI [1]
C1550483
Time specimen received
Description

Time specimen received

Data type

time

Alias
UMLS CUI [1,1]
C1514756
UMLS CUI [1,2]
C0040223
UMLS CUI [1,3]
C0370003
Date form completed
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1]
C1115437
Condition of specimen
Description

Specimen Condition

Data type

integer

Alias
UMLS CUI [1]
C1547869
Notes For Central Laboratory
Description

Comment

Data type

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1880016
Ccrr Module For S0100 Specimen Submission Form
Description

Ccrr Module For S0100 Specimen Submission Form

Alias
UMLS CUI-1
C0370003
UMLS CUI-2
C1515023
SWOG Patient ID
Description

Patient ID

Data type

text

Alias
UMLS CUI [1]
C2348585
SWOG Study No.
Description

Study Number

Data type

text

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0600091
Registration Step
Description

Registration Step

Data type

text

Alias
UMLS CUI [1]
C1514821
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Disease
Description

Leukemia/MDSClassification

Data type

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Institution/Affiliate
Description

Institution

Data type

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
Physician
Description

Treating Physician

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C25741
NCI Thesaurus ObjectClass-2
C25705
UMLS CUI [1]
C1710470
Contact Person at Institution
Description

ContactPersonatInstitution

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C25461
UMLS 2011AA ObjectClass-2
C0337611
Phone Number
Description

Phone Number

Data type

float

Alias
UMLS CUI [1]
C1515258
Group Name
Description

GroupName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Description

Study No.

Data type

text

Alias
UMLS CUI [1,1]
C0008976
UMLS CUI [1,2]
C0600091
Pt. ID
Description

Pt. ID

Data type

text

Alias
UMLS CUI [1]
C2348585
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No Instruction available.

1 forms
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Specimen
C0370003 (UMLS CUI-1)
Item
Type of Specimen
integer
C0456204 (UMLS CUI [1])
CL.1
Code List
Type of Specimen
CL Item
Tubes Of Blood (1)
CL Item
Tubes Of Bone Marrow (2)
CL Item
Tubes Of Serum (3)
CL Item
Tissue, Specify Site(s) (4)
CL Item
Slides, Type And Number (5)
CL Item
Karyotype(s), Number (6)
CL Item
Other, Specify (7)
Tissue
Item
Tissue, specify site
text
C0040300 (UMLS CUI [1,1])
C1515974 (UMLS CUI [1,2])
Item
Tissue state
integer
C0040300 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
CL.2
Code List
Tissue state
CL Item
Fresh (1)
CL Item
Frozen (2)
CL Item
Fixed (3)
number
Item
Slides, type and number
text
C1705201 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C1705201 (UMLS CUI [2,1])
C0332307 (UMLS CUI [2,2])
Karyotype
Item
Karotype(s), number
text
C1261273 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Specimen Collection Date
Item
Date specimen collected
date
C1302413 (UMLS CUI [1])
Specimen Collection Time
Item
Time specimen collected
time
C4064021 (UMLS CUI [1])
Other
Item
Other (typeofspecimen) , specify
text
C0456204 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Reasons For Specimen Submission
C0370003 (UMLS CUI-1)
C0392360 (UMLS CUI-2)
C1515023 (UMLS CUI-3)
Item
Status
integer
C0456204 (UMLS CUI [1,1])
C0449438 (UMLS CUI [1,2])
CL.3
Code List
Status
CL Item
Prestudy specimen (1)
CL Item
Complete remission/response specimen (2)
CL Item
Relapse/recurrence specimen (3)
CL Item
Other specimen (4)
Other specimen,specify
Item
Other specimen, specify
text
C0456204 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Completed By
Item
Completed By
text
C1550483 (UMLS CUI [1])
Date Form Completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C1115437 (UMLS CUI [1])
Comments
Item
Notes from submitting institution
text
C0947611 (UMLS CUI [1])
Item Group
Central Laboratory
C1880016 (UMLS CUI-1)
Central laboratory identification number
Item
Central laboratory identification number
text
C1880016 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date specimen received
Item
Date specimen received
date
C0011008 (UMLS CUI [1,1])
C2585542 (UMLS CUI [1,2])
Completed By
Item
Completed By
text
C1550483 (UMLS CUI [1])
Time specimen received
Item
Time specimen received
time
C1514756 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0370003 (UMLS CUI [1,3])
Date Form Completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C1115437 (UMLS CUI [1])
Item
Condition of specimen
integer
C1547869 (UMLS CUI [1])
CL.4
Code List
Condition of specimen
CL Item
Useable (1)
CL Item
Damaged Or Unusable (2)
CL Item
not usable as received; inadequate submission (3)
Comment
Item
Notes For Central Laboratory
text
C0947611 (UMLS CUI [1,1])
C1880016 (UMLS CUI [1,2])
Item Group
Ccrr Module For S0100 Specimen Submission Form
C0370003 (UMLS CUI-1)
C1515023 (UMLS CUI-2)
Patient ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Study Number
Item
SWOG Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Registration Step
Item
Registration Step
text
C1514821 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Leukemia/MDSClassification
Item
Disease
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Institution
Item
Institution/Affiliate
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Treating Physician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C25741 (NCI Thesaurus ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1710470 (UMLS CUI [1])
ContactPersonatInstitution
Item
Contact Person at Institution
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass-2)
C0337611 (UMLS 2011AA ObjectClass-2)
Phone Number
Item
Phone Number
float
C1515258 (UMLS CUI [1])
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Study No.
Item
Study No.
text
C0008976 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Pt. ID
Item
Pt. ID
text
C2348585 (UMLS CUI [1])
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