CCR Clinical Informatics

Visit Date^(m)

Enter the date the form was completed.

Note: If the information was obtained at multiple visits, please enter the date the form was completed.

DD-MMM-YYYY

30 Characters

Expected Collection Date of Specimen

DD-MMM-YYYY

Expected Collection Time of Specimen

Enter the planned or anticipated time when a sample (specimen) will be collected in military format (24 hours). Seconds are optional and default to 00 if not entered.

Ex: 13:56:00 (for 1:56:00 PM)

HH(24):MM:SS

Specimen Collected?

Select a Yes/ No/ Not Applicable answer to whether a sample/ specimen has been collected

Use pick list.

Collection Date

Enter the date when sample was collected.

DD-MMM-YYYY

Specimen Type

Select specimen type from the pick list: 

• BLOOD PRODUCT

• SLIDES

• TUMOR BLOCK

Use pick list.

Submitted Reason

Select the explanation for the submission of a biospecimen from a patient.

Use pick list.

Other, Specify

Enter the explanation for submission of a specimen that is different from a list of options.

100 characters

Amount Obtained

Enter the number that describes the amount of specimen included in the sample.

5 digits and 2 decimals

Specimen Unit

Use pick list.

Reason Specimen Not Collected

Select the reason a tissue specimen taken for research or analysis was not collected from the picklist:

• INSUFFICIENT SPECIMEN

• PATENT REFUSAL

• SPECIMEN UNAVAILABLE

• OTHER, SPECIFY

Use pick list.

Reason Specimen Not Collected; Other, specify

Use the free-text field to specify the reason a tissue specimen taken for research or analysis was not collected.

100 characters