ID

6182

Descripción

CALGB: SPECIMEN ROUTING FORM PLASMA Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-82EA-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-82EA-227A-E034-080020C9C0E0

Palabras clave

Versiones (2)
  1. 19/4/12 19/4/12 -
  2. 16/12/14 16/12/14 - Martin Dugas
Subido en

16 de diciembre de 2014

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00016276 Pathology - CALGB SPECIMEN ROUTING FORM PLASMA 2032060_v3_0

Alemán Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM PLASMA
    1. No Instruction available.
General information
Descripción

General information

Alias
UMLS CUI-1
C1508263
CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBProtocolNumber

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

Amended data?

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
UMLS CUI-1
C0680532
Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

To Be Completed By Submitting Institution
Descripción

To Be Completed By Submitting Institution

Blood Sample (plasma)
Descripción

BloodSample

Tipo de datos

text

Date plasma specimen collected
Descripción

Dateplasmaspecimencollected

Tipo de datos

text

CALGB Treatment Study
Descripción

CALGBTreatmentStudy

Tipo de datos

text

Does specimen accompany this form? (If yes, complete the remainder of this form.)
Descripción

Does specimen accompany this form?

Tipo de datos

boolean

If no, specify reason
Descripción

Ifno,specifyreason

Tipo de datos

text

Number of tubes submitted
Descripción

Number of tubes submitted

Tipo de datos

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ObjectClass
C41277
NCI Thesaurus Property
C25695
UMLS CUI-1
C0237753
UMLS CUI-2
C0370003
UMLS CUI-3
C1561954
UMLS CUI-4
C1515023
Date sample sent
Descripción

Date sample sent

Tipo de datos

date

Time Period Specimen Collected (mark one with an X)
Descripción

TimePeriodSpecimenCollected

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus Property
C25452
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
NCI Thesaurus ValueDomain
C25452
Responsible treating physician
Descripción

Responsibletreatingphysician:

Tipo de datos

text

Phone Number to be used in event of sample problems
Descripción

PhoneNumbertobeusedineventofsampleproblems:

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25461
UMLS 2011AA ObjectClass
C0337611
NCI Thesaurus Property
C28020
UMLS 2011AA Property
C0033213
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C40978
UMLS 2011AA Property
C1515258
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Completed By
Descripción

CompletedBy

Tipo de datos

text

Date Completed
Descripción

DateCompleted

Tipo de datos

text

To Be Completed By Receiving Institution/laboratory
Descripción

To Be Completed By Receiving Institution/laboratory

Date sample received
Descripción

Date sample received

Tipo de datos

date

Sample Condition (mark one with an X)
Descripción

Sample Condition

Tipo de datos

integer

Alias
NCI Thesaurus ObjectClass
C12801
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus ValueDomain
C25688
NCI Thesaurus Property
C25457
UMLS CUI-1
C2736123
Sample ID no.
Descripción

Sample ID no.

Tipo de datos

text

Number of Aliquots
Descripción

NumberofAliquots

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
Average aliquot volume (cc)
Descripción

Averagealiquotvolume

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25335
UMLS 2011AA Property
C0449468
NCI Thesaurus Property
C25414
UMLS 2011AA Property
C1510844
NCI Thesaurus ValueDomain
C25712
UMLS 2011AA ValueDomain
C1522609
NCI Thesaurus ValueDomain
C37917
UMLS 2011AA ValueDomain
C1510992
Sample received by
Descripción

Samplereceivedby

Tipo de datos

text

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: CALGB: SPECIMEN ROUTING FORM PLASMA
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
General information
C1508263 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Amended data
Item
Amended data?
boolean
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0680532 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
To Be Completed By Submitting Institution
BloodSample
Item
Blood Sample (plasma)
text
Dateplasmaspecimencollected
Item
Date plasma specimen collected
text
CALGBTreatmentStudy
Item
CALGB Treatment Study
text
Specimen with form
Item
Does specimen accompany this form? (If yes, complete the remainder of this form.)
boolean
Ifno,specifyreason
Item
If no, specify reason
text
Number of tubes submitted
Item
Number of tubes submitted
integer
C25337 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C41277 (NCI Thesaurus ObjectClass)
C25695 (NCI Thesaurus Property)
C0237753 (UMLS CUI-1)
C0370003 (UMLS CUI-2)
C1561954 (UMLS CUI-3)
C1515023 (UMLS CUI-4)
Date sample sent
Item
Date sample sent
date
Item
Time Period Specimen Collected (mark one with an X)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25452 (NCI Thesaurus Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
C25452 (NCI Thesaurus ValueDomain)
CL.3
Code List
Time Period Specimen Collected (mark one with an X)
CL Item
Pre-treatment (Pre-treatment)
CL Item
During Initial Treatment (During Initial Treatment)
CL Item
During Follow-up, No. Therapy (During Follow-Up, No. Therapy)
CL Item
At Relapse/progression (At Relapse/Progression)
Responsibletreatingphysician:
Item
Responsible treating physician
text
PhoneNumbertobeusedineventofsampleproblems:
Item
Phone Number to be used in event of sample problems
text
C25461 (NCI Thesaurus ObjectClass)
C0337611 (UMLS 2011AA ObjectClass)
C28020 (NCI Thesaurus Property)
C0033213 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C40978 (NCI Thesaurus Property)
C1515258 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
CompletedBy
Item
Completed By
text
DateCompleted
Item
Date Completed
text
Item Group
To Be Completed By Receiving Institution/laboratory
Date sample received
Item
Date sample received
date
Item
Sample Condition (mark one with an X)
integer
C12801 (NCI Thesaurus ObjectClass)
C19157 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C25457 (NCI Thesaurus Property)
C2736123 (UMLS CUI-1)
CL.4
Code List
Sample Condition (mark one with an X)
CL Item
Missing (0)
CL Item
Okay (1)
CL Item
Damaged (2)
CL Item
Insufficient Amount (3)
CL Item
Damaged But Stored (4)
CL Item
Thawed But Stored (5)
CL Item
Improperly Stored (6)
Specimen ID
Item
Sample ID no.
text
NumberofAliquots
Item
Number of Aliquots
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
Averagealiquotvolume
Item
Average aliquot volume (cc)
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25335 (NCI Thesaurus Property)
C0449468 (UMLS 2011AA Property)
C25414 (NCI Thesaurus Property)
C1510844 (UMLS 2011AA Property)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C37917 (NCI Thesaurus ValueDomain)
C1510992 (UMLS 2011AA ValueDomain)
Samplereceivedby
Item
Sample received by
text
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