ID

42744

Description

S0100 PATHOLOGY SUBMISSION FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB412F0-20C0-418F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB412F0-20C0-418F-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

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Creative Commons BY-NC 3.0 Legacy
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Leukemia null Pathology - S0100 PATHOLOGY SUBMISSION FORM - 2070699v3.0

English

Instructions: Submit a copy of this form to the SWOG Statistical Center. Mail required materials and this form to the following pathologist: David Head, MD Vanderbilt Clinical Labs 4605 TVC 1161 21st Ave. S. Nashville, TN 37232

1 forms  
Ccrr Module For S0100 Pathology Submission Form
Description

Ccrr Module For S0100 Pathology Submission Form

Alias
UMLS CUI-1
C0030664
UMLS CUI-2
C0023418
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
SWOG Patient ID
Description

Patient ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Patient Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
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
Reason for Submission
Description

Reason for Submission

Data type

text

Alias
UMLS CUI [1,1]
C0030673
UMLS CUI [1,2]
C0392360
No. of Slides
Description

Number of Slides

Data type

text

Alias
UMLS CUI [1,1]
C1705201
UMLS CUI [1,2]
C0449788
Date Sample Obtained
Description

Specimen Collection Date

Data type

date

Alias
UMLS CUI [1]
C1302413
1 W Peripheral Smear Slide, Enclosed
Description

Peripheral Smear Slide

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C2238079
UMLS CUI [1,2]
C1705201
1 WG Stained BM Aspirate Slide, Enclosed
Description

Aspirate Slide

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0370199
UMLS CUI [1,2]
C1705201
5 Unstained Smear Slides, Enclosed
Description

Unstained Smear Slides

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0444186
UMLS CUI [1,2]
C1705201
BM Report, Enclosed
Description

BM Report

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1]
C0684224
Pathology Submission form - Leukemia Addendum, Enclosed
Description

Leukemia Addendum

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0023418
UMLS CUI [1,2]
C1510776
1 Stained biopsy touch prep, Enclosed
Description

Stained biopsy touch prep

Data type

boolean

Alias
UMLS CUI [1,1]
C0005558
UMLS CUI [1,2]
C2986582
UMLS CUI [1,3]
C2827487
4 Unstained biopsy touch preps, Enclosed
Description

Unstained biopsy touch preps

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0005558
UMLS CUI [1,2]
C2827487
UMLS CUI [1,3]
C1883469
1 H&E section of the biopsy, Enclosed
Description

H&E biopsy

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0523207
UMLS CUI [1,2]
C0005558
4 Unstained peripheral blood smears, Enclosed
Description

Unstained peripheral blood smears

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C2238079
UMLS CUI [1,2]
C1705201
UMLS CUI [1,3]
C1883469
Specimen #
Description

Specimen ID

Data type

text

Alias
UMLS CUI [1,1]
C0370003
UMLS CUI [1,2]
C0600091
Notes
Description

Comments

Data type

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C0030664
UMLS CUI [1,3]
C0023418
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Similar models

Instructions: Submit a copy of this form to the SWOG Statistical Center. Mail required materials and this form to the following pathologist: David Head, MD Vanderbilt Clinical Labs 4605 TVC 1161 21st Ave. S. Nashville, TN 37232

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For S0100 Pathology Submission Form
C0030664 (UMLS CUI-1)
C0023418 (UMLS CUI-2)
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 ID
Item
SWOG Patient ID
text
C2348585 (UMLS CUI [1])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
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])
Item
Reason for Submission
text
C0030673 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
CL.1
Code List
Reason for Submission
CL Item
Prestudy (Prestudy)
Number of Slides
Item
No. of Slides
text
C1705201 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Specimen Collection Date
Item
Date Sample Obtained
date
C1302413 (UMLS CUI [1])
Peripheral Smear Slide
Item
1 W Peripheral Smear Slide, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C2238079 (UMLS CUI [1,1])
C1705201 (UMLS CUI [1,2])
Aspirate Slide
Item
1 WG Stained BM Aspirate Slide, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0370199 (UMLS CUI [1,1])
C1705201 (UMLS CUI [1,2])
Unstained Smear Slides
Item
5 Unstained Smear Slides, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0444186 (UMLS CUI [1,1])
C1705201 (UMLS CUI [1,2])
BM Report
Item
BM Report, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0684224 (UMLS CUI [1])
Leukemia Addendum
Item
Pathology Submission form - Leukemia Addendum, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0023418 (UMLS CUI [1,1])
C1510776 (UMLS CUI [1,2])
Stained biopsy touch prep
Item
1 Stained biopsy touch prep, Enclosed
boolean
C0005558 (UMLS CUI [1,1])
C2986582 (UMLS CUI [1,2])
C2827487 (UMLS CUI [1,3])
Unstained biopsy touch preps
Item
4 Unstained biopsy touch preps, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0005558 (UMLS CUI [1,1])
C2827487 (UMLS CUI [1,2])
C1883469 (UMLS CUI [1,3])
H&E biopsy
Item
1 H&E section of the biopsy, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C0523207 (UMLS CUI [1,1])
C0005558 (UMLS CUI [1,2])
Unstained peripheral blood smears
Item
4 Unstained peripheral blood smears, Enclosed
boolean
C25180 (NCI Thesaurus ValueDomain)
C2238079 (UMLS CUI [1,1])
C1705201 (UMLS CUI [1,2])
C1883469 (UMLS CUI [1,3])
Specimen ID
Item
Specimen #
text
C0370003 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Comments
Item
Notes
text
C0947611 (UMLS CUI [1,1])
C0030664 (UMLS CUI [1,2])
C0023418 (UMLS CUI [1,3])
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