This paper worksheet may be completed to faciliate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General information
C1508263 (UMLS CUI-1)
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property)
C1549740 (UMLS CUI-1)
CombinedInstitutionName
Item
Institution/Affiliate
text
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C1550483 (UMLS CUI-1)
C1301584 (UMLS CUI-2)
Person Completing Form First Name
Item
Person Completing Form, First Name
text
C1550483 (UMLS CUI-1)
C1443235 (UMLS CUI-2)
Person Completing Form Phone
Item
Person Completing Form, Phone
text
C1550483 (UMLS CUI-1)
C0039457 (UMLS CUI-2)
Amended data
Item
Are data amended
boolean
C0680532 (UMLS CUI-1)
Date form completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
Item
Reason form completed
integer
C25638 (NCI Thesaurus ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C15445 (NCI Thesaurus ObjectClass)
CL.2
Code List
Reason form completed
CL Item
Patient Will Not Begin Hormonal Therapy (1)
CL Item
Patient Received Less Than 5 Years Of Hormonal Therapy, And Hormonal Treatment Has Ended (2)
CL Item
Patient Received 5 Years Of Hormonal Therapy, And Hormonal Treatment Has Ended (3)
CL Item
Patient Received 5 Years Of Hormonal Therapy, And Hormonal Treatment Will Continue (4)
Item Group
Hormone therapy
C0279025 (UMLS CUI-1)
Item
Agent Name
integer
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C1254351 (UMLS CUI-1)
Agent
Code List
Agent Name
CL Item
Tamoxifen (1)
CL Item
Aromatase Inhibitor (2)
CL Item
Other (specify) (3)
Other hormone therapy
Item
Other hormone therapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
Agent administered
Item
Was agent administered
boolean
C38147 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1254351 (UMLS CUI-1)
C1521801 (UMLS CUI-2)
Agent Start Date
Item
Agent Start Date
date
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0451613 (UMLS CUI-1)
Agent End Date
Item
Agent End Date (Leave date boxes blank if agent will continue beyond 5 years.)
date
C25164 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0850893 (UMLS CUI-1)
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