This paper worksheet may be completed to facilitate the entry of Thyroid Function information (TSH) information in NSABP Coordinator Online. Partially completed worksheets 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
Header
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Item Group
Tsh Assessment
Item
Time point (for this report)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
CL.1
Code List
Time point (for this report)
CL Item
6 Weeks After Start Of Study Therapy (6 weeks after start of study therapy)
CL Item
3 Months After Randomization (3 months after randomization)
CL Item
6 Months After Randomization (6 months after randomization)
CL Item
9 Months After Randomization (9 months after randomization)
CL Item
12 Months After Randomization (12 months after randomization)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
LaboratoryProcedureThyroidStimulatingHormoneThyrotropinMeasurementInd-2
Item
Was TSH assessed at this time point
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C2280 (NCI Thesaurus Property)
C0040160 (UMLS 2011AA Property)
C64813 (NCI Thesaurus Property-2)
C0202230 (UMLS 2011AA Property-2)
Item Group
Tsh Assessment1
AgentPlaceboSunitinibMalateAdministeredInd-2
Item
Was the patient being treated with sunitinib/placebo at the time of this assessment
boolean
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C753 (NCI Thesaurus Property)
C0032042 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C26673 (NCI Thesaurus Property-3)
C1698963 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
LevothyroxineAgentAdministeredInd-2
Item
Was the patient being treated with levothyroxine at the time of this assessment
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C62080 (NCI Thesaurus ObjectClass-2)
C1881373 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
LevothyroxineAgentInitiationAdministeredInd-2
Item
Was levothyroxine initiated as a result of this assessment (If no)
boolean
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C62080 (NCI Thesaurus ObjectClass-2)
C1881373 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C47938 (NCI Thesaurus Property-2)
C1704686 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Levothyroxine Dose (if either question is marked yes)
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C62080 (NCI Thesaurus ObjectClass-2)
C1881373 (UMLS 2011AA ObjectClass-2)
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Levothyroxine Dose (if either question is marked yes)
CL Item
0.1 Mg Daily (0.1 mg daily)
CL Item
0.125 Mg Daily (0.125 mg daily)
CL Item
0.15 Mg Daily (0.15 mg daily)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
LevothyroxineAgentDoseAdministeredSpecify
Item
Other, specify (mg daily)
text
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C62080 (NCI Thesaurus ObjectClass-2)
C1881373 (UMLS 2011AA ObjectClass-2)
C25488 (NCI Thesaurus Property)
C0178602 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus ValueDomain-2)
C1521801 (UMLS 2011AA ValueDomain-2)
Item Group
Tsh Assessment2
Assessment Date
Item
Date of Assessment (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C2985720 (UMLS CUI-1)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C38000 (NCI Thesaurus Property)
LaboratoryProcedureThyroidStimulatingHormoneThyrotropinMeasurementOutcomeUnspecifiedValue
Item
TSH (patient value microIU/mL)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C2280 (NCI Thesaurus Property-2)
C0040160 (UMLS 2011AA Property-2)
C64813 (NCI Thesaurus Property-3)
C0202230 (UMLS 2011AA Property-3)
C38046 (NCI Thesaurus ValueDomain)
C0205370 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureThyroidStimulatingHormoneThyrotropinMeasurementLowerLimitofNormalValue
Item
TSH LLN (microIU/mL)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C2280 (NCI Thesaurus Property)
C0040160 (UMLS 2011AA Property)
C64813 (NCI Thesaurus Property-2)
C0202230 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25555 (NCI Thesaurus ValueDomain-2)
C1518030 (UMLS 2011AA ValueDomain-2)
LaboratoryProcedureThyroidStimulatingHormoneThyrotropinMeasurementUpperLimitofNormalValue
Item
TSH ULN (microIU/mL)
float
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C2280 (NCI Thesaurus Property)
C0040160 (UMLS 2011AA Property)
C64813 (NCI Thesaurus Property-2)
C0202230 (UMLS 2011AA Property-2)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
C25706 (NCI Thesaurus ValueDomain-2)
C1519815 (UMLS 2011AA ValueDomain-2)
PriorSystemicTherapyInvasiveBreastCarcinomaSecondaryMalignantNeoplasmAdministeredInd-2
Item
Did the patient receive any systemic anticancer treatment for documented invasive breast cancer recurrence or second primary cancer prior to this Time Point
boolean
C15698 (NCI Thesaurus ObjectClass)
C1515119 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C4968 (NCI Thesaurus Property)
C0751623 (UMLS 2011AA Property)
C9245 (NCI Thesaurus Property-2)
C0853879 (UMLS 2011AA Property-2)
C25382 (NCI Thesaurus Property-3)
C1521801 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Item
Reason TSH was Assessed at Other Time Point (When Other Time Point applies)
text
C64813 (NCI Thesaurus ObjectClass)
C0202230 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C68568 (NCI Thesaurus Property-3)
C2348792 (UMLS 2011AA Property-2)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.8
Code List
Reason TSH was Assessed at Other Time Point (When Other Time Point applies)
CL Item
Evaluation Of Symptoms (Evaluation of Symptoms)
CL Item
Follow-up After Discontinuation Of Levothyroxine (Follow-up after Discontinuation of Levothyroxine)
CL Item
Follow-up Of Previous Assessment (Follow-up of Previous Assessment)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
ThyrotropinMeasurementOtherTimepointAssessmentSpecify
Item
Other, specify
text
C64813 (NCI Thesaurus ObjectClass)
C0202230 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C68568 (NCI Thesaurus Property-3)
C2348792 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Footer
Research Comments
Item
Comments (optional)
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form
Item
Person Completing Form
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Date Form Completed
Item
Date Form Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
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