ID

9403

Beskrivning

PATHOLOGY SUBMISSION REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE248E1-B493-53AD-E034-0003BA12F5E7

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE248E1-B493-53AD-E034-0003BA12F5E7

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy

Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Itemgroup-kommentar för :

Item-kommentar för :


Inga kommentarer

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Breast Cancer NCT00090974 Transmittal - PATHOLOGY SUBMISSION REPORT - 2059549v3.0

To be submitted with Form 1 - Eligibility Checklist and Initial Evaluation within 6 weeks of randomization

Patient Information
Beskrivning

Patient Information

Patient Study ID, Coordinating Group (NCIC CTG Patient Serial Number)
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (first - middle - last)
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Beskrivning

PatientMedicalRecordNumber

Datatyp

text

Investigator Name
Beskrivning

InvestigatorName

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Registered Investigator (NCI Investigator #)
Beskrivning

RegisteredInvestigator

Datatyp

text

Pathology Submission
Beskrivning

Pathology Submission

Specimen Collection Date - Pathology (yyyy mmm dd)
Beskrivning

SpecimenCollectionDate

Datatyp

date

Pathology Institution Name (at which the pathology specimens are held)
Beskrivning

AddressPathologyInstitutionName

Datatyp

text

Address: Dept./Building
Beskrivning

AddressPathologyDepartment

Datatyp

text

Street name and Number
Beskrivning

AddressPathologyStreet

Datatyp

text

City
Beskrivning

Address,City

Datatyp

text

State/Province
Beskrivning

AddressPathologyProvince

Datatyp

text

Country
Beskrivning

AddressPathologyCountry

Datatyp

text

Postal Code
Beskrivning

AddressPathologyPostalCode

Datatyp

text

Reviewing Pathologist (Diagnosing Pathologists)
Beskrivning

PathologistName,Reviewing

Datatyp

text

Specimen ID number (Pathology accession number #)
Beskrivning

SpecimenID

Datatyp

float

Comments
Beskrivning

Comments

COMMENTS
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

Investigator Signature

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

Person Completing Form, First Name
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Beskrivning

FormCompletionDate,Original

Datatyp

date

Ccrr Module For Pathology Submission Report
Beskrivning

Ccrr Module For Pathology Submission Report

Similar models

To be submitted with Form 1 - Eligibility Checklist and Initial Evaluation within 6 weeks of randomization

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group (NCIC CTG Patient Serial Number)
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)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InvestigatorName
Item
Investigator Name
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Pathology Submission
SpecimenCollectionDate
Item
Specimen Collection Date - Pathology (yyyy mmm dd)
date
AddressPathologyInstitutionName
Item
Pathology Institution Name (at which the pathology specimens are held)
text
AddressPathologyDepartment
Item
Address: Dept./Building
text
AddressPathologyStreet
Item
Street name and Number
text
Address,City
Item
City
text
AddressPathologyProvince
Item
State/Province
text
AddressPathologyCountry
Item
Country
text
AddressPathologyPostalCode
Item
Postal Code
text
PathologistName,Reviewing
Item
Reviewing Pathologist (Diagnosing Pathologists)
text
SpecimenID
Item
Specimen ID number (Pathology accession number #)
float
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
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)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Pathology Submission Report

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

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