ID

42743

Beschrijving

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

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 21-08-17 21-08-17 -
  3. 17-09-21 17-09-21 -
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17 september 2021

DOI

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Licentie

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

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Specimen
Beschrijving

Specimen

Alias
UMLS CUI-1
C0370003
Type of Specimen
Beschrijving

Type of Specimen

Datatype

integer

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

Tissue

Datatype

text

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

Tissue state

Datatype

integer

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

number

Datatype

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
Beschrijving

Karyotype

Datatype

text

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

Specimen Collection Date

Datatype

date

Alias
UMLS CUI [1]
C1302413
Time specimen collected
Beschrijving

Specimen Collection Time

Datatype

time

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

Other

Datatype

text

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

Reasons For Specimen Submission

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

Clinical Status Specimen

Datatype

integer

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

Other specimen,specify

Datatype

text

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

Completed By

Datatype

text

Alias
UMLS CUI [1]
C1550483
Date form completed
Beschrijving

Date Form Completed

Datatype

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
Beschrijving

Comments

Datatype

text

Alias
UMLS CUI [1]
C0947611
Central Laboratory
Beschrijving

Central Laboratory

Alias
UMLS CUI-1
C1880016
Central laboratory identification number
Beschrijving

Central laboratory identification number

Datatype

text

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

Date specimen received

Datatype

date

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

Completed By

Datatype

text

Alias
UMLS CUI [1]
C1550483
Time specimen received
Beschrijving

Time specimen received

Datatype

time

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

Date Form Completed

Datatype

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
Beschrijving

Specimen Condition

Datatype

integer

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

Comment

Datatype

text

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

Ccrr Module For S0100 Specimen Submission Form

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

Patient ID

Datatype

text

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

Study Number

Datatype

text

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

Registration Step

Datatype

text

Alias
UMLS CUI [1]
C1514821
Patient Initials
Beschrijving

Patient Initials

Datatype

text

Alias
UMLS CUI [1]
C2986440
Disease
Beschrijving

Leukemia/MDSClassification

Datatype

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
Beschrijving

Institution

Datatype

text

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

Treating Physician

Datatype

text

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

ContactPersonatInstitution

Datatype

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
Beschrijving

Phone Number

Datatype

float

Alias
UMLS CUI [1]
C1515258
Group Name
Beschrijving

GroupName

Datatype

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.
Beschrijving

Study No.

Datatype

text

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

Pt. ID

Datatype

text

Alias
UMLS CUI [1]
C2348585
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No Instruction available.

1 Formulieren
  1. StudyEvent: S0100 SPECIMEN SUBMISSION FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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