ID

9228

Beschrijving

Southwest Oncology Group S0201 Specimen Submission Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA795E-3805-1204-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A8BA795E-3805-1204-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
Geüploaded op

9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) null Pathology - Southwest Oncology Group S0201 Specimen Submission Form - 2055735v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Southwest Oncology Group S0201 Specimen Submission Form
    1. No Instruction available.
Unnamed 1
Beschrijving

Unnamed 1

SWOG Patient No
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Reg Type
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Disease
Beschrijving

Disease

Datatype

text

Institution/Member
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
Beschrijving

TreatingPhysician

Datatype

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
Contact Person at Institution
Beschrijving

ContactPersonatInstitution

Datatype

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass-2
C25461
UMLS 2011AA ObjectClass-2
C0337611
Telephone No. (Groups other than SWOG)
Beschrijving

PhoneNumber

Datatype

float

Group Name
Beschrijving

GroupName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Study No.
Beschrijving

StudyNo.

Datatype

text

Pt. No
Beschrijving

Pt.ID

Datatype

text

Specimen
Beschrijving

Specimen

Type of specimen (check only one)
Beschrijving

TypeofSpecimen

Datatype

text

Tissue, specify sites
Beschrijving

Tissue,specifysites

Datatype

text

Tissue, check one
Beschrijving

SpecimenState

Datatype

text

Slides, type and number
Beschrijving

Slides,typeandnumber

Datatype

text

karyotype, number
Beschrijving

KaryotypeCount

Datatype

float

Date specimen collected
Beschrijving

SpecimenCollectionDate

Datatype

date

Time specimen collected
Beschrijving

SpecimenCollectionTime

Datatype

date

Reasons for specimen submission (Check all that apply)
Beschrijving

SpecimenSubmittedReason

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Other specimen, specify (reason for submission)
Beschrijving

Otherspecimen,specify(reasonforsubmission)

Datatype

text

Treatment study No.
Beschrijving

SpecimenID

Datatype

float

Unnamed 2
Beschrijving

Unnamed 2

By
Beschrijving

By

Datatype

text

Date
Beschrijving

SpecimenSubmitDate

Datatype

date

Notes from central laboratory
Beschrijving

Comments

Datatype

text

For Central Laboratory Use Only
Beschrijving

For Central Laboratory Use Only

Central laboratory identification number
Beschrijving

Centrallaboratoryidentificationnumber

Datatype

text

By
Beschrijving

By

Datatype

text

time specimen received
Beschrijving

SpecimenReceivedTime

Datatype

date

Notes from central laboratory
Beschrijving

Comments

Datatype

text

condition of specimen (check only one)
Beschrijving

SpecimenCondition

Datatype

text

Date
Beschrijving

SpecimenReceivedDate

Datatype

date

Date
Beschrijving

SpecimenReceivedDate

Datatype

date

Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form
Beschrijving

Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Southwest Oncology Group S0201 Specimen Submission Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed 1
SWOGPatientID
Item
SWOG Patient No
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Reg Type
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Disease
Item
Disease
text
MainMemberInstitution/Affiliate
Item
Institution/Member
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
ContactPersonatInstitution
Item
Contact Person at Institution
text
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25461 (NCI Thesaurus ObjectClass-2)
C0337611 (UMLS 2011AA ObjectClass-2)
PhoneNumber
Item
Telephone No. (Groups other than SWOG)
float
GroupName
Item
Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
StudyNo.
Item
Study No.
text
Pt.ID
Item
Pt. No
text
Item Group
Specimen
Item
Type of specimen (check only one)
text
CL.1
Code List
Type of specimen (check only one)
CL Item
Tubes Of Blood (tubes of blood)
CL Item
Tubes Of Bone Marrow (tubes of bone marrow)
CL Item
Tubes Of Serum (tubes of serum)
CL Item
Tissue, Specify Site(s) (tissue)
CL Item
Slides, Type And Number (slides)
CL Item
Karyotype(s), Number (karyotype)
CL Item
Other, Specify (other, specify)
Tissue,specifysites
Item
Tissue, specify sites
text
Item
Tissue, check one
text
CL.2
Code List
Tissue, check one
CL Item
Fresh (fresh)
CL Item
Frozen (frozen)
CL267638 (NCI Metathesaurus)
CL Item
parrafin embedded (parrafin embedded)
Slides,typeandnumber
Item
Slides, type and number
text
KaryotypeCount
Item
karyotype, number
float
SpecimenCollectionDate
Item
Date specimen collected
date
SpecimenCollectionTime
Item
Time specimen collected
date
Item
Reasons for specimen submission (Check all that apply)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
CL.3
Code List
Reasons for specimen submission (Check all that apply)
CL Item
Prestudy Submission (prestudy submission)
CL Item
Complete Remission/response Specimen (complete remission/response specimen)
CL Item
Relapse/recurrence Specimen (relapse/recurrence specimen)
CL Item
Other Specimen, Specify (other specimen, specify)
Otherspecimen,specify(reasonforsubmission)
Item
Other specimen, specify (reason for submission)
text
SpecimenID
Item
Treatment study No.
float
Item Group
Unnamed 2
By
Item
By
text
SpecimenSubmitDate
Item
Date
date
Comments
Item
Notes from central laboratory
text
Item Group
For Central Laboratory Use Only
Centrallaboratoryidentificationnumber
Item
Central laboratory identification number
text
By
Item
By
text
SpecimenReceivedTime
Item
time specimen received
date
Comments
Item
Notes from central laboratory
text
Item
condition of specimen (check only one)
text
CL.4
Code List
condition of specimen (check only one)
CL Item
Useable (usable as received)
CL Item
Damaged Or Unusable (not usable as received; adequate submission)
CL Item
Damaged Or Unusable (not usable as received; inadequate submission)
SpecimenReceivedDate
Item
Date
date
SpecimenReceivedDate
Item
Date
date
Item Group
Ccrr Module For Southwest Oncology Group S0201 Specimen Submission Form
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