AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) 3369057v1.0
AIDS and Cancer Specimen Resource (ACSR) Procurement Form (F37) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=

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  1. StudyEvent: SE.0000
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
HospitalAdmissionOrdinalNumber
Item
Visit number
double
Item Group
Specimen Procurement
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
AIDSMalignancyConsortiumSpecimenProcurementInd-2
Item
Specimen(s) obtained for donation to ACSR
boolean
Item
Specimen Type (check all that apply)
text
Code List
Specimen Type (check all that apply)
CL Item
Serum (Serum)
CL Item
Plasma (Plasma)
CL Item
Pbmc (peripheral Blood Mononuclear Cells) (PBMC)
CL Item
Peripheral Blood (Blood)
CL Item
Tissue (Tissue)
CL Item
Other (Other)
SpecimenCellSourceSpecify
Item
Other specify
text
Item
ACSR site the specimen(s) shipped to
text
Code List
ACSR site the specimen(s) shipped to
CL Item
Gwu (GWU)
CL Item
Ucsf (UCSF)
CL Item
Jhu (JHU)
CL Item
Other (Other)
AIDSMalignancyConsortiumSpecimenProcurementSpecify
Item
Other, specify
text
Item
If specimens were not obtained for ACSR, please indicate reason
text
Code List
If specimens were not obtained for ACSR, please indicate reason
CL Item
Patient Had Previously Donated Specimen To Acsr (Patient had previously donated specimen to ACSR)
CL Item
Patient Refused To Give Informed Consent For Acsr Specimen Donation (Patient refused to give informed consent for ACSR specimen donation)
CL Item
Patient Was Not Asked To Consider Acsr Specimen Donation (Patient was not asked to consider ACSR specimen donation)
CL Item
Other (Other)
AIDSMalignancyConsortiumSpecimenNotSubmittedSpecify
Item
Other, specify
text
SpecimenCollectedDate
Item
Date Specimen Obtained (for previously donated specimens mm/dd/yyyy)
date
Item Group
Study Coordinator
AIDSMalignancyConsortiumPersonStudyCoordinatorName
Item
Study Coordinator's name
text
ResponsiblePersonE-mailAddressText
Item
E-mail
text
OrganizationPhoneNumber
Item
Phone Number (xxx-xxx-xxxx)
text
Item Group
Comments
ResearchCommentsText
Item
Comments
text