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1 forms
  1. StudyEvent: ABTR01B1: Specimen Shipping Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PatientCOGIdentifierNumber
Item
Patient Identifier
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)
Patient Initials
Item
Name
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Person Completing Form
Item
Modifier
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Amendment date
Item
Date Last Modified
date
C19464 (NCI Thesaurus ObjectClass)
C0680532 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Disease / Patient Status
Item
Disease/Patient Status at time of sampling
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
CL.1
Code List
Disease/Patient Status at time of sampling
CL Item
Diagnosis Of Primary (Diagnosis of Primary)
CL Item
Second-look Surgery (Second Look Surgery)
C15317 (NCI Thesaurus)
C0949626 (UMLS 2011AA)
CL Item
Progression Or Relapse (Relapse)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Second Malignancy (Diagnosis of Secondary Malignancy)
PatientAccessionNumber
Item
Accession Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25402 (NCI Thesaurus Property)
C1510755 (UMLS 2011AA Property)
NewCancerDiagnosisDate
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
PrimaryCancerDiagnosisICD-OCode
Item
Central Review Diagnosis [ICD-O Morphology]
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
DiseasePrimarySiteICD-OCode
Item
Institutional assessment of site of disease [ICD-O Topography]
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
Item
Tumor stage
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C38027 (NCI Thesaurus Property)
C1519504 (UMLS 2011AA Property)
CL.2
Code List
Tumor stage
CL Item
I (1)
CL Item
Ii (2)
CL Item
Iii (3)
CL Item
Iv (4)
CL Item
V (5)
CL Item
Unknown/not Applicable (Unknown/NA)
TumorGroupingStageSpecify
Item
Other Disease-Specific Stage
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C38027 (NCI Thesaurus Property)
C1519504 (UMLS 2011AA Property)
PatientOtherIdentifierNumber
Item
BPC Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Shipping Information
ShippingCompanyIdentifierName
Item
Carrier
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C54131 (NCI Thesaurus ObjectClass)
C0683757 (UMLS 2011AA ObjectClass)
C40353 (NCI Thesaurus ObjectClass-2)
C1524049 (UMLS 2011AA ObjectClass-2)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
InstitutionShippingCompanyIdentifierNumber
Item
Account Number
text
C41206 (NCI Thesaurus ObjectClass)
C1272753 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C54131 (NCI Thesaurus Property-2)
C0683757 (UMLS 2011AA Property-2)
C40353 (NCI Thesaurus Property-3)
C1524049 (UMLS 2011AA Property-3)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
SpecimenShippingCompanyIdentifierNumber
Item
Carrier Tracking Number
text
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C54131 (NCI Thesaurus Property-2)
C0683757 (UMLS 2011AA Property-2)
C40353 (NCI Thesaurus Property-3)
C1524049 (UMLS 2011AA Property-3)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
SpecimenLabSubmittedDate
Item
Date Shipped
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property-2)
C1515023 (UMLS 2011AA Property-2)
Item
Source of Tissue Sample
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.3
Code List
Source of Tissue Sample
CL Item
Primary (primary)
C25251 (NCI Thesaurus)
C0205225 (UMLS 2011AA)
CL Item
Distant Metastases (metastasis)
CL Item
Recurrent Tumor (recurrence)
CL Item
Other, Specify (other)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Patient Status Information
Item
Chemotherapy Status
text
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.4
Code List
Chemotherapy Status
CL Item
Pre-treatment (Pre-chemotherapy)
CL Item
Post-treatment (Post-chemotherapy)
CL024863 (NCI Metathesaurus)
Item
XRT Status
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
CL.5
Code List
XRT Status
CL Item
Pre-treatment (Pre-XRT)
CL Item
Post-treatment (Post-XRT)
CL024863 (NCI Metathesaurus)
TissueSpecimenRadiationFieldTakenInd-2
Item
was sample from radiation port? (If Post-XRT,)
boolean
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
C54648 (NCI Thesaurus Property)
C1882536 (UMLS 2011AA Property)
C25701 (NCI Thesaurus Property-2)
C1883727 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
TumorSpecimenSpecialtyInd-2
Item
Is this a rare tumor?
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C17153 (NCI Thesaurus Property)
C0037778 (UMLS 2011AA Property)
PrimaryCancerDiagnosisICD-OCode
Item
Central Review Diagnosis [ICD-O Morphology]
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
TumorMalignantPresentPercentageAmount
Item
Percent Tumor Estimate
float
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C14143 (NCI Thesaurus Property-2)
C0205282 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25417 (NCI Thesaurus ValueDomain-2)
Item
Material sent
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.8
Code List
Material sent
CL Item
Frozen Tissue, Not Fixed, Without The Use Of Oct (Snap Frozen Tumor/Tissue)
CL Item
Frozen Tissue, Not Fixed, Embedded With Oct (OCT Embedded Tumor/Tissue)
CL Item
Tissue Fixed With Formalin (Formalin Fixed Tissue)
CL Item
Peripheral Blood (Blood)
C0229664 (NCI Metathesaurus)
C0229664 (NCI Metathesaurus-2)
CL Item
Bone Marrow (Bone Marrow)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Serum (Serum)
C13325 (NCI Thesaurus)
C0229671 (UMLS 2011AA)
C13325 (NCI Thesaurus-3)
C0229671 (UMLS 2011AA-4)
CL Item
Stained Slides (Stained Slides)
CL Item
Unstained Slides (Unstained Slides)
CL Item
Paraffin Blocks (Paraffin block(s))
SpecimenSiteICD-OCode
Item
Sites from which specimen was taken [ICD-O Topography]
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
SpecimenCollectedDate
Item
Date Specimen Obtained
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-2)
C2745955 (UMLS 2011AA Property)
Item
Paperwork Sent
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25375 (NCI Thesaurus Property)
C0684224 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
CL.9
Code List
Paperwork Sent
CL Item
Specimen Shipment Form (ABTR01B1 Shipping Form)
CL Item
Pathology Report(s) (Copy of Pathology Report)
CL Item
Pathology Checklist (Copy of Pathology Checklist)
CL Item
Operative Report(s) (Copy of Operative Report)
SpecimenResearchConsentRelatedInd-3
Item
Has informed consent been given to for the patient's specimens to be used in research to learn about, prevent, or treat cancer? (Consent Instruction 1:)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property-2)
C1511481 (UMLS 2011AA Property)
BloodTissueSpecimenOtherDiseasesandDisordersResearchConsentInd-3
Item
Has informed consent been given to for the patient's specimens to be used in research to learn about other health problems? (Consent Instruction 2:)
boolean
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C12434 (NCI Thesaurus ObjectClass-2)
C0229664 (UMLS 2011AA ObjectClass-2)
C19157 (NCI Thesaurus ObjectClass-3)
C0370003 (UMLS 2011AA ObjectClass-3)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C15319 (NCI Thesaurus Property-2)
C2991 (NCI Thesaurus Property-3)
C0012634 (UMLS 2011AA Property-2)
C25460 (NCI Thesaurus Property-4)
C1511481 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Permission to contact Patient
Item
Has informed consent been given for contact sometime in the future about taking part in more research? (Consent Instruction 3:)
boolean
C16960 (NCI Thesaurus ObjectClass)
C1522577 (UMLS CUI-1)
C67527 (NCI Thesaurus Property)
C0521104 (UMLS CUI-2)
C25460 (NCI Thesaurus Property-2)
C16452 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
Item Group
Ccrr Module For Abtr01b1: Specimen Shipping Form
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