ID

6198

Description

AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

Keywords

  1. 12/18/14 12/18/14 - Martin Dugas
Uploaded on

December 18, 2014

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.

AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) 3369057v1.0

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Header Module
Description

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Description

HospitalAdmissionOrdinalNumber

Data type

double

Specimen Procurement
Description

Specimen Procurement

Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
Description

SpecimenCollectedDate

Data type

date

Specimen(s) obtained for donation to ACSR
Description

AIDSMalignancyConsortiumSpecimenProcurementInd-2

Data type

boolean

Specimen Type (check all that apply)
Description

SpecimenSubmittedType

Data type

text

Other specify
Description

SpecimenCellSourceSpecify

Data type

text

ACSR site the specimen(s) shipped to
Description

AIDSMalignancyConsortiumSpecimenProcurementType

Data type

text

Other, specify
Description

AIDSMalignancyConsortiumSpecimenProcurementSpecify

Data type

text

If specimens were not obtained for ACSR, please indicate reason
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedReason

Data type

text

Other, specify
Description

AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify

Data type

text

Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
Description

SpecimenCollectedDate

Data type

date

Study Coordinator
Description

Study Coordinator

Study Coordinator's name
Description

AIDSMalignancyConsortiumPersonStudyCoordinatorName

Data type

text

E-mail
Description

ResponsiblePersonE-mailAddressText

Data type

text

Phone Number (xxx-xxx-xxxx)
Description

OrganizationPhoneNumber

Data type

text

Comments
Description

Comments

Comments
Description

ResearchCommentsText

Data type

text

Similar models

No Instruction available.

  1. StudyEvent: SE.0000
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
HospitalAdmissionOrdinalNumber
Item
Visit number
double
Item Group
Specimen Procurement
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
AIDSMalignancyConsortiumSpecimenProcurementInd-2
Item
Specimen(s) obtained for donation to ACSR
boolean
Item
Specimen Type (check all that apply)
text
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
CL Item
Plasma (Plasma)
CL Item
Pbmc (peripheral Blood Mononuclear Cells) (PBMC)
CL Item
Peripheral Blood (Blood)
CL Item
Tissue (Tissue)
CL Item
Other (Other)
SpecimenCellSourceSpecify
Item
Other specify
text
Item
ACSR site the specimen(s) shipped to
text
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucsf (UCSF)
CL Item
Jhu (JHU)
CL Item
Other (Other)
AIDSMalignancyConsortiumSpecimenProcurementSpecify
Item
Other, specify
text
Item
If specimens were not obtained for ACSR, please indicate reason
text
Code List
If specimens were not obtained for ACSR, please indicate reason
CL Item
Patient Had Previously Donated Specimen To Acsr (Patient had previously donated specimen to ACSR)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused to give informed consent for ACSR specimen donation)
CL Item
Patient Was Not Asked To Consider Acsr Specimen Donation (Patient was not asked to consider ACSR specimen donation)
CL Item
Other (Other)
AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify
Item
Other, specify
text
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
Item Group
Study Coordinator
AIDSMalignancyConsortiumPersonStudyCoordinatorName
Item
Study Coordinator's name
text
ResponsiblePersonE-mailAddressText
Item
E-mail
text
OrganizationPhoneNumber
Item
Phone Number (xxx-xxx-xxxx)
text
Item Group
Comments
ResearchCommentsText
Item
Comments
text

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