ID

6178

Descrizione

ECOG MATERIAL SUBMISSION FORM (E2100) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC221735-7106-1535-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC221735-7106-1535-E034-0003BA12F5E7

Keywords

versioni (1)
  1. 15/12/14 15/12/14 - Martin Dugas
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15 dicembre 2014

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Breast Cancer Pathology - ECOG MATERIAL SUBMISSION FORM (E2100) - 2068992v3.0

Inglese

Form No. 1479, ECOG MATERIAL SUBMISSION FORM

1 moduli  
  1. StudyEvent: ECOG MATERIAL SUBMISSION FORM (E2100)
    1. Form No. 1479, ECOG MATERIAL SUBMISSION FORM
General information
Descrizione

General information

Alias
UMLS CUI-1
C1508263
Patient's Name
Descrizione

Patient's Name

Tipo di dati

text

Alias
UMLS CUI-1
C1299487
ECOG Patient ID
Descrizione

ECOG Patient ID

Tipo di dati

text

Alias
UMLS CUI-1
C1549740
ECOG Patient ID
Descrizione

ECOG Patient ID

Tipo di dati

text

Alias
UMLS CUI-1
C1549740
ECOG Protocol No.
Descrizione

ECOG Protocol No.

Tipo di dati

text

Alias
UMLS CUI-1
C2985699
ECOG Protocol No.
Descrizione

ECOG Protocol No.

Tipo di dati

text

Alias
UMLS CUI-1
C2985699
Registration Step
Descrizione

RegistrationStep

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Participating Group Patient ID
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Institution/Affiliate
Descrizione

MainMemberInstitution/Affiliate

Tipo di dati

text

Part A
Descrizione

Part A

Date Material(s) collected (M D Y)
Descrizione

DateMaterial(s)collected

Tipo di dati

date

Date Material(s) sent to lab (M D Y)
Descrizione

DateMaterial(s)senttolab

Tipo di dati

date

Sample type
Descrizione

Sample type

Tipo di dati

integer

Tissue/material type
Descrizione

Tissue/materialtype

Tipo di dati

text

other, specify in Comments (tissue/material type)
Descrizione

other,specifyinComments(tissue/materialtype)

Tipo di dati

text

Type of collection/stain/process
Descrizione

Typeofcollection/stain/process

Tipo di dati

text

slides/fixed, specify in Comments (type of collection/stain/process)
Descrizione

slides/fixed,specifyinComments(typeofcollection/stain/process)

Tipo di dati

text

other, specify in Comments (type of collection/stain/process)
Descrizione

other,specifyinComments(typeofcollection/stain/process)

Tipo di dati

text

Timing of material collection
Descrizione

Timingofmaterialcollection

Tipo di dati

text

Alias
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25453
UMLS 2011AA Property
C1516698
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
other, specify in Comments (timing of material collection)
Descrizione

other,specifyinComments(timingofmaterialcollection)

Tipo di dati

text

Number of specimens (tubes, slides, etc.) submitted (FOR LEUKEMIA STUDIES ONLY)
Descrizione

Numberofspecimens(tubes,slides,etc.)submitted

Tipo di dati

double

Diagnosis
Descrizione

Diagnosis

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C15220
UMLS 2011AA ObjectClass
C0011900
other, specify in Comments (diagnosis)
Descrizione

other,specifyinComments(diagnosis)

Tipo di dati

text

Absolute Blast count
Descrizione

AbsoluteBlastcount

Tipo di dati

double

Insititution contact name
Descrizione

Insititutioncontactname

Tipo di dati

text

Contact Phone Number (International)
Descrizione

CentralLaboratoryContactTelephoneNumber

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Contact FAX Number (International)
Descrizione

CentralLaboratoryContactFaxNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25210
UMLS 2011AA Property
C0085205
Part B
Descrizione

Part B

Central Laboratory Name
Descrizione

PathologyCoreFacilityLaboratoryIdentifierName

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C37984
UMLS 2011AA ObjectClass
C0022877
NCI Thesaurus ObjectClass
C18189
UMLS 2011AA ObjectClass
C0030664
NCI Thesaurus ObjectClass
C15896
UMLS 2011AA ObjectClass
C1511521
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C42614
UMLS 2011AA ValueDomain
C0027365
Central Laboratory Contact Name
Descrizione

CentralLaboratoryContactPersonName

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C37984
UMLS 2011AA ObjectClass
C0022877
NCI Metathesaurus ObjectClass
C0205099
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
Sample type
Descrizione

Sample type

Tipo di dati

integer

Date Material(s) received at central lab (M D Y)
Descrizione

DateMaterial(s)receivedatcentrallab

Tipo di dati

date

Condition of Material(s)
Descrizione

ConditionofMaterial(s)

Tipo di dati

text

Lab Specimen ID Numbers
Descrizione

LabSpecimenIDNumbers

Tipo di dati

text

Aliquots of sample made
Descrizione

Aliquots of sample made

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1522602
Contact Phone Number (International)
Descrizione

CentralLaboratoryContactTelephoneNumber

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25395
UMLS 2011AA Property
C0039457
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Contact FAX Number (International)
Descrizione

CentralLaboratoryContactFaxNumber

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus ObjectClass
C64207
UMLS 2011AA ObjectClass
C1880016
NCI Thesaurus Property
C25210
UMLS 2011AA Property
C0085205
Comments
Descrizione

Comments

Comments
Descrizione

Comments

Tipo di dati

text

Ritorna all'inizio della pagina

Similar models

Form No. 1479, ECOG MATERIAL SUBMISSION FORM

1 moduli
  1. StudyEvent: ECOG MATERIAL SUBMISSION FORM (E2100)
    1. Form No. 1479, ECOG MATERIAL SUBMISSION FORM
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
General information
C1508263 (UMLS CUI-1)
Patient Name
Item
Patient's Name
text
C1299487 (UMLS CUI-1)
Patient ID
Item
ECOG Patient ID
text
C1549740 (UMLS CUI-1)
Patient ID
Item
ECOG Patient ID
text
C1549740 (UMLS CUI-1)
Study Protocol Document Version
Item
ECOG Protocol No.
text
C2985699 (UMLS CUI-1)
Study Protocol Document Version
Item
ECOG Protocol No.
text
C2985699 (UMLS CUI-1)
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Part A
DateMaterial(s)collected
Item
Date Material(s) collected (M D Y)
date
DateMaterial(s)senttolab
Item
Date Material(s) sent to lab (M D Y)
date
Item
Sample type
integer
CL.6
Code List
Sample type
CL Item
Sample Type #1 (1)
CL Item
Sample Type #2 (2)
CL Item
Sample Type #3 (3)
CL Item
Sample Type #4 (4)
Item
Tissue/material type
text
CL.2
Code List
Tissue/material type
CL Item
Peripheral Blood (peripheral blood)
C0229664 (NCI Metathesaurus)
CL Item
Bone Marrow Aspirate (bone marrow aspirate)
CL042344 (NCI Metathesaurus)
CL Item
Bone Marrow Biopsy (bone marrow biopsy)
C15193 (NCI Thesaurus)
C0005954 (UMLS 2011AA)
CL Item
Plasma (plasma)
C13356 (NCI Thesaurus)
C0032105 (UMLS 2011AA)
CL Item
Serum (serum)
C13325 (NCI Thesaurus)
C0229671 (UMLS 2011AA)
CL Item
Urine (urine)
C13283 (NCI Thesaurus)
C0042036 (UMLS 2011AA)
CL Item
Sputum (sputum)
C13278 (NCI Thesaurus)
C0038056 (UMLS 2011AA)
CL Item
Karyotypes (karyotypes)
CL Item
Skin Punch Biopsy (skin punch biopsy)
CL Item
Other, Specify In Comments (other, specify in Comments)
other,specifyinComments(tissue/materialtype)
Item
other, specify in Comments (tissue/material type)
text
Item
Type of collection/stain/process
text
CL.3
Code List
Type of collection/stain/process
CL Item
Green Top (heparinized) (green top (heparinized))
CL Item
Red Top (red top)
CL Item
Yellow Top (acd) (yellow top (ACD))
CL Item
Purple Top (edta) (purple top (EDTA))
CL Item
Blue (sodium Citrate) (blue (sodium citrate))
CL Item
Pcli (PCLI)
CL Item
Slides/unstained (slides/unstained)
CL Item
Slides/air Dried Smear (slides/air dried smear)
CL Item
Slides/fixed, Specify In Comments (slides/fixed, specify in Comments)
CL Item
Slides/h & E (slides/H & E)
CL Item
Slides/wright Stain (slides/Wright stain)
CL Item
Rpmi (RPMI)
CL Item
Other, Specify In Comments (other, specify in Comments)
slides/fixed,specifyinComments(typeofcollection/stain/process)
Item
slides/fixed, specify in Comments (type of collection/stain/process)
text
other,specifyinComments(typeofcollection/stain/process)
Item
other, specify in Comments (type of collection/stain/process)
text
Item
Timing of material collection
text
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.4
Code List
Timing of material collection
CL Item
Pre-study/baseline (pre-study/baseline)
CL Item
Complete Remission/response (complete remission/response)
CL Item
Partial Remission/response (partial remission/response)
CL Item
Progression (progression)
C25331 (NCI Thesaurus)
CL Item
Relapse (relapse)
C18265 (NCI Thesaurus)
CL Item
Other, Specify In Comments (other, specify in Comments)
other,specifyinComments(timingofmaterialcollection)
Item
other, specify in Comments (timing of material collection)
text
Numberofspecimens(tubes,slides,etc.)submitted
Item
Number of specimens (tubes, slides, etc.) submitted (FOR LEUKEMIA STUDIES ONLY)
double
Item
Diagnosis
text
C15220 (NCI Thesaurus ObjectClass)
C0011900 (UMLS 2011AA ObjectClass)
CL.5
Code List
Diagnosis
CL Item
acute myeloid leukemia (acute myeloid leukemia)
CL Item
acute lymphocytic leukemia (acute lymphocytic leukemia)
CL Item
CML - blast cells (CML - blast cells)
CL Item
chronic lymphocytic leukemia (chronic lymphocytic leukemia)
CL Item
CML - chronic phase (CML - chronic phase)
CL Item
MDS - myelodysplastic syndrome (MDS - myelodysplastic syndrome)
CL Item
other, specify in Comments (other, specify in Comments)
CL Item
unknown (unknown)
other,specifyinComments(diagnosis)
Item
other, specify in Comments (diagnosis)
text
AbsoluteBlastcount
Item
Absolute Blast count
double
Insititutioncontactname
Item
Insititution contact name
text
CentralLaboratoryContactTelephoneNumber
Item
Contact Phone Number (International)
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)
CentralLaboratoryContactFaxNumber
Item
Contact FAX Number (International)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C64207 (NCI Thesaurus ObjectClass)
C1880016 (UMLS 2011AA ObjectClass)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
Item Group
Part B
PathologyCoreFacilityLaboratoryIdentifierName
Item
Central Laboratory Name
text
C37984 (NCI Thesaurus ObjectClass)
C0022877 (UMLS 2011AA ObjectClass)
C18189 (NCI Thesaurus ObjectClass)
C0030664 (UMLS 2011AA ObjectClass)
C15896 (NCI Thesaurus ObjectClass)
C1511521 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
CentralLaboratoryContactPersonName
Item
Central Laboratory Contact 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)
Item
Sample type
integer
CL.6
Code List
Sample type
CL Item
Sample Type #1 (1)
CL Item
Sample Type #2 (2)
CL Item
Sample Type #3 (3)
CL Item
Sample Type #4 (4)
DateMaterial(s)receivedatcentrallab
Item
Date Material(s) received at central lab (M D Y)
date
Item
Condition of Material(s)
text
CL.7
Code List
Condition of Material(s)
CL Item
Not Usable As Received (not usable as received)
CL Item
Usable As Received (usable as received)
LabSpecimenIDNumbers
Item
Lab Specimen ID Numbers
text
Aliquots of sample made
Item
Aliquots of sample made
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS CUI-1)
CentralLaboratoryContactTelephoneNumber
Item
Contact Phone Number (International)
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)
CentralLaboratoryContactFaxNumber
Item
Contact FAX Number (International)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C64207 (NCI Thesaurus ObjectClass)
C1880016 (UMLS 2011AA ObjectClass)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
Item Group
Comments
Comments
Item
Comments
text
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