ID

6268

Descrição

CALGB: 80101 BLOOD SAMPLE TRACKING FORM Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-FA7B-5976-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA6CD3D-FA7B-5976-E034-080020C9C0E0

Palavras-chave

Versões (3)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 02/06/2015 02/06/2015 -
  3. 03/06/2015 03/06/2015 -
Transferido a

18 de dezembro de 2014

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Esophageal Cancer NCT00052910 Pathology - CALGB: 80101 BLOOD SAMPLE TRACKING FORM - 2029956v3.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: CALGB: 80101 BLOOD SAMPLE TRACKING FORM
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBProtocolNumber

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Date form submitted
Descrição

Dateformsubmitted

Tipo de dados

text

Amended data?
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Descrição

Unnamed2

Patient's Name
Descrição

PatientName,Last

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroupCode

Tipo de dados

text

Patient Hospital Number
Descrição

PatientMedicalRecordNumber

Tipo de dados

text

Participating Group Protocol No.
Descrição

Particip.GroupProtocolNumber

Tipo de dados

double

Main Member Institution/Adjunct
Descrição

InstitutionName

Tipo de dados

text

Participating Group Patient No.
Descrição

PatientStudyID,ParticipatingGroup

Tipo de dados

text

To Be Completed By Submitting Institution
Descrição

To Be Completed By Submitting Institution

Does specimen accompany this form?
Descrição

Specimenw/FormInd

Tipo de dados

text

Specify reason
Descrição

Specifyreason

Tipo de dados

text

Date sample collected
Descrição

SpecimenCollectionDate

Tipo de dados

date

Number of tubes of whole blood submitted with this form
Descrição

WholeBloodTubesSubmittedCount

Tipo de dados

double

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C41067
UMLS 2011AA ObjectClass
C1608383
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
NCI Metathesaurus Property
C0175730
Sample time Point
Descrição

SpecimenCollectionTime

Tipo de dados

text

Submitted by
Descrição

PersonSpecimenSubmittedName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Phone #
Descrição

PhoneNumber

Tipo de dados

double

To Be Completed By Receiving Institution/laboratory
Descrição

To Be Completed By Receiving Institution/laboratory

Date sample received
Descrição

SpecimenReceivedDate

Tipo de dados

date

Sample ID no.
Descrição

SpecimenID

Tipo de dados

double

Received by
Descrição

PersonSpecimenReceivedName

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25639
UMLS 2011AA Property
C1514756
NCI Thesaurus Property
C19157
UMLS 2011AA Property
C0370003
Is sample evaluable for analysis?
Descrição

SpecimenEvaluableInd

Tipo de dados

text

Phone #
Descrição

PhoneNumber

Tipo de dados

double

Sample condition
Descrição

Samplecondition

Tipo de dados

text

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: CALGB: 80101 BLOOD SAMPLE TRACKING FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Dateformsubmitted
Item
Date form submitted
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
double
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Item Group
To Be Completed By Submitting Institution
Item
Does specimen accompany this form?
text
CL.2
Code List
Does specimen accompany this form?
CL Item
No, Specify Reason (No, specify reason)
CL Item
Yes, Complete The Remainder Of Form (Yes, complete the remainder of form)
Specifyreason
Item
Specify reason
text
SpecimenCollectionDate
Item
Date sample collected
date
WholeBloodTubesSubmittedCount
Item
Number of tubes of whole blood submitted with this form
double
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C41067 (NCI Thesaurus ObjectClass)
C1608383 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
C0175730 (NCI Metathesaurus Property)
Item
Sample time Point
text
CL.3
Code List
Sample time Point
CL Item
1-pre-study (1-pre-study)
PersonSpecimenSubmittedName
Item
Submitted by
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
PhoneNumber
Item
Phone #
double
Item Group
To Be Completed By Receiving Institution/laboratory
SpecimenReceivedDate
Item
Date sample received
date
SpecimenID
Item
Sample ID no.
double
PersonSpecimenReceivedName
Item
Received by
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C19157 (NCI Thesaurus Property)
C0370003 (UMLS 2011AA Property)
Item
Is sample evaluable for analysis?
text
CL.5
Code List
Is sample evaluable for analysis?
CL Item
No, Procedural Deviations Definitely Affect Analysis (No, procedural deviations definitely affect analysis)
CL Item
Yes, Sample Is Evaluable (Yes, sample is evaluable)
CL Item
Unsure, Procedural Deviations May Affect Analysis (Unsure, procedural deviations may affect analysis)
PhoneNumber
Item
Phone #
double
Item
Sample condition
text
CL.4
Code List
Sample condition
CL Item
Okay (Okay)
CL Item
Damaged (Damaged)
CL Item
Missing (Missing)
CL Item
Thawed (Thawed)
CL Item
Insufficient Amount (Insufficient amount)
CL Item
Clotted (Clotted)
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