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

  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

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Leukemia null Pathology - S0100 PATHOLOGY SUBMISSION FORM - 2070699v3.0

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

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

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

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])
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])

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial