ID

9210

Description

Pathology Submission Report Gefitinib in Treating Patients With Non-Small Cell Lung Cancer That Has Been Surgically Removed Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A069EFF3-E6C4-50D8-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A069EFF3-E6C4-50D8-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00049543 Pathology - Pathology Submission Report - 2034358v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Pathology Submission Report
    1. No Instruction available.
1. Patient Information
Description

1. Patient Information

NCIC CTG Patient Serial #
Description

PatientStudyID,CoordinatingGroup

Data type

text

Hospital #
Description

PatientMedicalRecordNumber

Data type

text

Patient Initials (first-middle-last)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Intergroup Patient Serial #
Description

PatientStudyID,ParticipatingGroup

Data type

text

Site #
Description

NCIInstitutionNumber

Data type

text

Patient's Social Security # (USA only)
Description

PatientSocialSecurityNumber

Data type

float

Institution
Description

InstitutionName

Data type

text

Investigator
Description

RegisteredInvestigator

Data type

text

2. Pathology Submission
Description

2. Pathology Submission

Date tissue obtained for diagnosis
Description

SpecimenCollectionDate

Data type

date

Name of Institution
Description

AddressPathologyInstitutionName

Data type

text

Address
Description

Address

Data type

text

Contact Pathologist Name
Description

PathologistName,Reviewing

Data type

text

Pathology specimen number(s)
Description

SpecimenID

Data type

float

3. Comments
Description

3. Comments

3. COMMENTS
Description

Comments

Data type

text

4. Investigator Signature
Description

4. Investigator Signature

Signature of Responsible Investigator
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Name of Clinical Research Associate
Description

PersonCompletingForm,LastName

Data type

text

Date
Description

FormCompletionDate,Original

Data type

date

Ncic Ctg Use Only
Description

Ncic Ctg Use Only

Logged
Description

LoggedEntryInitials

Data type

text

Header
Description

LoggedEntryDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Study Coord
Description

CoordinatorReviewInitials

Data type

text

Unnamed2
Description

CoordinatorReviewDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Phy
Description

PhysicianReviewInitials

Data type

text

Data Ent'd
Description

DataEntryInitials

Data type

text

Verified
Description

DataVerificationInitials

Data type

text

Ccrr Module For Pathology Submission Report
Description

Ccrr Module For Pathology Submission Report

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Address, Department
Description

AddressPathologyDepartment

Data type

text

Address, Street
Description

AddressPathologyStreet

Data type

text

Address Postal Code
Description

AddressPathologyPostalCode

Data type

text

Address Province
Description

AddressPathologyProvince

Data type

text

Address Country
Description

AddressPathologyCountry

Data type

text

Address City
Description

AddressPathologyCity

Data type

text

State
Description

State

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Pathology Submission Report
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
1. Patient Information
PatientStudyID,CoordinatingGroup
Item
NCIC CTG Patient Serial #
text
PatientMedicalRecordNumber
Item
Hospital #
text
Patient Initials
Item
Patient Initials (first-middle-last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientStudyID,ParticipatingGroup
Item
Intergroup Patient Serial #
text
NCIInstitutionNumber
Item
Site #
text
PatientSocialSecurityNumber
Item
Patient's Social Security # (USA only)
float
InstitutionName
Item
Institution
text
RegisteredInvestigator
Item
Investigator
text
Item Group
2. Pathology Submission
SpecimenCollectionDate
Item
Date tissue obtained for diagnosis
date
AddressPathologyInstitutionName
Item
Name of Institution
text
Address
Item
Address
text
PathologistName,Reviewing
Item
Contact Pathologist Name
text
SpecimenID
Item
Pathology specimen number(s)
float
Item Group
3. Comments
Comments
Item
3. COMMENTS
text
Item Group
4. Investigator Signature
InvestigatorSignature
Item
Signature of Responsible Investigator
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Name of Clinical Research Associate
text
FormCompletionDate,Original
Item
Date
date
Item Group
Ncic Ctg Use Only
LoggedEntryInitials
Item
Logged
text
LoggedEntryDate
Item
Header
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CoordinatorReviewInitials
Item
Study Coord
text
CoordinatorReviewDate
Item
Unnamed2
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PhysicianReviewInitials
Item
Phy
text
DataEntryInitials
Item
Data Ent'd
text
DataVerificationInitials
Item
Verified
text
Item Group
Ccrr Module For Pathology Submission Report
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
AddressPathologyDepartment
Item
Address, Department
text
AddressPathologyStreet
Item
Address, Street
text
AddressPathologyPostalCode
Item
Address Postal Code
text
AddressPathologyProvince
Item
Address Province
text
AddressPathologyCountry
Item
Address Country
text
AddressPathologyCity
Item
Address City
text
State
Item
State
text
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