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AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Sunitinib Malate in Treating HIV-Positive Patients With Cancer Undergoing Highly Active Antiretroviral Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7158429B-AC2E-967C-E040-BB89AD4302A7

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Versionen (3)
  1. 26.08.12 26.08.12 -
  2. 08.07.15 08.07.15 -
  3. 08.07.15 08.07.15 -
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26. August 2012

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    Brain and Central Nervous System Tumors NCT00890747 Pathology - AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) - 2933133v1.0

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
      1. No Instruction available.
    Unnamed1
    Beschreibung

    Unnamed1

    Visit number
    Beschreibung

    HospitalAdmissionOrdinalNumber

    Datentyp

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Thesaurus Property
    C25385
    UMLS 2011AA Property
    C0809949
    Unnamed2
    Beschreibung

    Unnamed2

    Specimen(s) obtained for donation to ACSR
    Beschreibung

    AIDSMalignancyConsortiumSpecimenProcurementInd-2

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C54153
    UMLS 2011AA Property
    C1709695
    Specimen Type (check all that apply)
    Beschreibung

    SpecimenSubmittedType

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    Other specify
    Beschreibung

    SpecimenCellSourceSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C12508
    UMLS 2011AA Property
    C0007634
    NCI Thesaurus Property
    C25683
    UMLS 2011AA Property
    C0449416
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    ACSR site the specimen(s) shipped to
    Beschreibung

    AIDSMalignancyConsortiumSpecimenProcurementType

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C54153
    UMLS 2011AA Property
    C1709695
    Other, specify
    Beschreibung

    AIDSMalignancyConsortiumSpecimenProcurementSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C54153
    UMLS 2011AA Property
    C1709695
    If specimens were not obtained for ACSR, please indicate reason
    Beschreibung

    AIDSMalignancyConsortiumSpecimenNotSubmittedReason

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    Other, specify
    Beschreibung

    AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C25594
    UMLS 2011AA Property
    C1518422
    NCI Thesaurus Property
    C25695
    UMLS 2011AA Property
    C1515023
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    Beschreibung

    SpecimenCollectedDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25452
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    Beschreibung

    SpecimenCollectedDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C19157
    UMLS 2011AA ObjectClass
    C0370003
    NCI Thesaurus Property
    C25452
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Study Coordinator
    Beschreibung

    Study Coordinator

    Study Coordinator's name
    Beschreibung

    AIDSMalignancyConsortiumPersonStudyCoordinatorName

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass
    C19707
    UMLS 2011AA ObjectClass
    C1515830
    NCI Thesaurus Property
    C51880
    UMLS 2011AA Property
    C1710220
    E-mail
    Beschreibung

    ResponsiblePersonE-mailAddressText

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C42775
    UMLS 2011AA Property
    C1705961
    Phone Number (xxx-xxx-xxxx)
    Beschreibung

    OrganizationPhoneNumber

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25395
    UMLS 2011AA Property
    C0039457
    NCI Thesaurus ObjectClass
    C19711
    UMLS 2011AA ObjectClass
    C1522486
    Comments
    Beschreibung

    Comments

    Comments
    Beschreibung

    ResearchCommentsText

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Zum Seitenanfang zurückkehren

    Ähnliche Modelle

    No Instruction available.

    1 Formulare
    1. StudyEvent: AMC-061 AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37)
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Unnamed1
    HospitalAdmissionOrdinalNumber
    Item
    Visit number
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C25385 (NCI Thesaurus Property)
    C0809949 (UMLS 2011AA Property)
    Item Group
    Unnamed2
    Item
    Specimen(s) obtained for donation to ACSR
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C54153 (NCI Thesaurus Property)
    C1709695 (UMLS 2011AA Property)
    CL.1
    Code List
    Specimen(s) obtained for donation to ACSR
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Specimen Type (check all that apply)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    CL.2
    Code List
    Specimen Type (check all that apply)
    CL Item
    Serum (Serum)
    C13325 (NCI Thesaurus)
    C0229671 (UMLS 2011AA)
    C13325 (NCI Thesaurus)
    C0229671 (UMLS 2011AA)
    CL Item
    Plasma (Plasma)
    C13356 (NCI Thesaurus)
    C0032105 (UMLS 2011AA)
    C13356 (NCI Thesaurus)
    C0032105 (UMLS 2011AA)
    CL Item
    Pbmc (peripheral Blood Mononuclear Cells) (PBMC)
    CL Item
    Peripheral Blood (Blood)
    C0229664 (NCI Metathesaurus)
    C0229664 (NCI Metathesaurus)
    CL Item
    Tissue (Tissue)
    C12801 (NCI Thesaurus)
    C0040300 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    SpecimenCellSourceSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C12508 (NCI Thesaurus Property)
    C0007634 (UMLS 2011AA Property)
    C25683 (NCI Thesaurus Property)
    C0449416 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    Item
    ACSR site the specimen(s) shipped to
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C54153 (NCI Thesaurus Property)
    C1709695 (UMLS 2011AA Property)
    CL.3
    Code List
    ACSR site the specimen(s) shipped to
    CL Item
    Gwu (GWU)
    CL Item
    Ucla (UCLA)
    CL Item
    Ucsf (UCSF)
    CL Item
    Osu (OSU)
    CL Item
    Suny/hscb (SUNY/HSCB)
    CL Item
    Jhu (JHU)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    AIDSMalignancyConsortiumSpecimenProcurementSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C54153 (NCI Thesaurus Property)
    C1709695 (UMLS 2011AA Property)
    Item
    If specimens were not obtained for ACSR, please indicate reason
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    CL.4
    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)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify
    Item
    Other, specify
    text
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C25594 (NCI Thesaurus Property)
    C1518422 (UMLS 2011AA Property)
    C25695 (NCI Thesaurus Property)
    C1515023 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    SpecimenCollectedDate
    Item
    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    SpecimenCollectedDate
    Item
    Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass)
    C0370003 (UMLS 2011AA ObjectClass)
    C25452 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    Item Group
    Study Coordinator
    AIDSMalignancyConsortiumPersonStudyCoordinatorName
    Item
    Study Coordinator's name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C19707 (NCI Thesaurus ObjectClass)
    C1515830 (UMLS 2011AA ObjectClass)
    C51880 (NCI Thesaurus Property)
    C1710220 (UMLS 2011AA Property)
    ResponsiblePersonE-mailAddressText
    Item
    E-mail
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C42775 (NCI Thesaurus Property)
    C1705961 (UMLS 2011AA Property)
    OrganizationPhoneNumber
    Item
    Phone Number (xxx-xxx-xxxx)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25395 (NCI Thesaurus Property)
    C0039457 (UMLS 2011AA Property)
    C19711 (NCI Thesaurus ObjectClass)
    C1522486 (UMLS 2011AA ObjectClass)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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