This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed worksheets may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. Following receipt of a Cardiac Report form (Form CR), the documentation will be reviewed to determine if routine submission of a Cardiac Report Follow-up form (Form CR-F) will be required. The decision will be conveyed to the institution's Program Coordinator. If cardiac follow-up is required, Form CR-F must be submitted for 2 years, approximately every 6 months following the date of confirmatory LVEF reported on Form CR. (Submission of Form CR-F should be timed to coincide with submission of the B-47 Follow-up form (Form F).)

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
Reporting Period
Item
Reporting Period
text
C25284 (NCI Thesaurus ValueDomain)
C2347804 (UMLS CUI-1)
C25214 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus ObjectClass-2)
CL.1
Code List
Reporting Period
CL Item
First Cardiac Follow-up (First cardiac follow-up)
CL Item
Second Cardiac Follow-up (Second cardiac follow-up)
CL Item
Third Cardiac Follow-up (Third cardiac follow-up)
CL Item
Fourth Cardiac Follow-up (Fourth cardiac follow-up)
Reporting Period End Date
Item
Reporting Period End Date (Month Day Year)
date
C25164 (NCI Thesaurus ValueDomain)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
Item Group
Cardiac Information
SymptomaticCongestiveHeartFailurePresentInd-3
Item
Has the patient had symptoms of CHF since the previous report (Previous report will be Form CR if this is the first CR-F form submitted.)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C3080 (NCI Thesaurus ObjectClass)
C0018802 (UMLS 2011AA ObjectClass)
C25269 (NCI Thesaurus ObjectClass-2)
C0231220 (UMLS 2011AA ObjectClass-2)
Item
How would you classify the symptoms of congestive heart failure (If yes)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C3080 (NCI Thesaurus ObjectClass-2)
C0018802 (UMLS 2011AA ObjectClass-2)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL.3
Code List
How would you classify the symptoms of congestive heart failure (If yes)
CL Item
Ordinary Physical Activity Does Not Cause Undue Fatigue, Palpitation, Dyspnea Or Anginal Pain (Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain)
CL Item
Asymptomatic At Rest, But Ordinary Physical Activity Results In Fatigue, Palpitation, Dyspnea Or Anginal Pain (Asymptomatic at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain)
CL Item
Asymptomatic At Rest, But Less Than Ordinary Physical Activity Results In Fatigue, Palpitation, Dyspnea Or Anginal Pain (Asymptomatic at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain)
CL Item
Symptomatic At Rest, Or Any Physical Activity Results In Fatigue, Palpitation, Dyspnea Or Anginal Pain (Symptomatic at rest, or any physical activity results in fatigue, palpitation, dyspnea or anginal pain)
LeftVentricularEjectionFractionAssessmentInd-2
Item
Has the patient had one or more LVEF assessments since the previous report (Form LVA should be submitted any time through 10 years following randomization when a non-protocol specified LVEF assessment has been performed because the patient has signs or symptoms of CHF see Protocol Section 5.3. Please submit all LVEF assessments since the previous report)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C37946 (NCI Thesaurus ObjectClass)
C2700377 (UMLS 2011AA ObjectClass)
HeartMedicationAdministrationInd-2
Item
Has the patient received medications for heart failure and/or hypertension since the previous report
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass-2)
C0013227 (UMLS 2011AA ObjectClass-2)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
Item
Medications (Mark all that apply)
text
C2079 (NCI Thesaurus ObjectClass)
C0007209 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C29848 (NCI Thesaurus Property-2)
C0439234 (UMLS 2011AA Property-2)
C25639 (NCI Thesaurus Property-3)
C1514756 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
Medications (Mark all that apply)
CL Item
Ace Inhibitor (ACE inhibitors)
CL Item
Alpha/beta Blocker (Alpha/beta blocker)
CL Item
Arb (ARB)
CL Item
Beta Blocker (Beta blockers)
CL Item
Cardiac Glycoside (Cardiac glycoside)
CL Item
Diuretic (Diuretics)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CardiacMedicationReportingPeriodSpecify
Item
Other, specify
text
C13306 (NCI Thesaurus ObjectClass)
C1522601 (UMLS 2011AA ObjectClass)
C459 (NCI Thesaurus ObjectClass-2)
C0013227 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property-2)
C0700287 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Medication Reason (Mark all reasons that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property-2)
C0348080 (UMLS 2011AA Property-2)
CL.7
Code List
Medication Reason (Mark all reasons that apply)
CL Item
Heart Failure (Heart Failure)
C50577 (NCI Thesaurus)
C0018801 (UMLS 2011AA)
CL Item
Hypertension (hypertension)
C3117 (NCI Thesaurus)
C0020538 (UMLS 2011AA)
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
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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