ID

9403

Description

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

Lien

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

Mots-clés

Versions (2)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

9 janvier 2015

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00090974 Transmittal - PATHOLOGY SUBMISSION REPORT - 2059549v3.0

Anglais

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

1 Formulaires  
Patient Information
Description

Patient Information

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

PatientStudyID,CoordinatingGroup

Type de données

text

Patient Initials (first - middle - last)
Description

Patient Initials

Type de données

text

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

PatientMedicalRecordNumber

Type de données

text

Investigator Name
Description

InvestigatorName

Type de données

text

Institution Name
Description

InstitutionName

Type de données

text

Registered Investigator (NCI Investigator #)
Description

RegisteredInvestigator

Type de données

text

Pathology Submission
Description

Pathology Submission

Specimen Collection Date - Pathology (yyyy mmm dd)
Description

SpecimenCollectionDate

Type de données

date

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

AddressPathologyInstitutionName

Type de données

text

Address: Dept./Building
Description

AddressPathologyDepartment

Type de données

text

Street name and Number
Description

AddressPathologyStreet

Type de données

text

City
Description

Address,City

Type de données

text

State/Province
Description

AddressPathologyProvince

Type de données

text

Country
Description

AddressPathologyCountry

Type de données

text

Postal Code
Description

AddressPathologyPostalCode

Type de données

text

Reviewing Pathologist (Diagnosing Pathologists)
Description

PathologistName,Reviewing

Type de données

text

Specimen ID number (Pathology accession number #)
Description

SpecimenID

Type de données

float

Comments
Description

Comments

COMMENTS
Description

Comments

Type de données

text

Investigator Signature
Description

Investigator Signature

Investigator Signature
Description

InvestigatorSignature

Type de données

text

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

PersonCompletingForm,LastName

Type de données

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Type de données

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)
Description

FormCompletionDate,Original

Type de données

date

Ccrr Module For Pathology Submission Report
Description

Ccrr Module For Pathology Submission Report

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Similar models

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

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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
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