Breast Cancer NCT00093795 Pathology - NSABP Worksheet for Pregnancy Event Form - 3006894v1.0

NSABP Worksheet for Pregnancy Event Form Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Positive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7EDC1E5D-3817-778E-E040-BB89AD432648

This paper worksheet may be completed to facilitate the entry of the pregnancy event information in NSABP Coordinator Online. Please complete if a patient or the sexual partner of an NSABP patient becomes pregnant during study therapy or within 6 months of completing study therapy. A follow-up report may be necessary to report the pregnancy outcome (e.g., normal baby, birth defect). Partially completed online forms may be saved in Coordinator Online.

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
Patient Initials
Item
Patient Initials
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
Unnamed 1
Patient Initials
Item
Patient Initials
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)
TreatingPhysicianOrParticipatingInvestigatorName
Item
Treating Investigator
text
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C37998 (NCI Thesaurus ObjectClass-2)
C1518602 (UMLS 2011AA ObjectClass-2)
C51883 (NCI Thesaurus ObjectClass-3)
C1710470 (UMLS 2011AA ObjectClass-3)
C25936 (NCI Thesaurus ObjectClass-4)
C0035173 (UMLS 2011AA ObjectClass-4)
C25191 (NCI Thesaurus Property)
C1547383 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
Person Completing Form
Item
Person Completing Form (Reporter)
text
C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Person Completing Form Phone
Item
Phone (Reporter)
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
ResponsiblePersonFaxNumber
Item
Fax (Reporter)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C1273518 (UMLS 2011AA ObjectClass-2)
C25210 (NCI Thesaurus Property)
C0085205 (UMLS 2011AA Property)
ResponsiblePersonE-mailAddressText
Item
E-mail (Reporter)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C42775 (NCI Thesaurus Property)
C1705961 (UMLS 2011AA 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)
Item Group
Cancer Treatment Prior To Pregnancy Diagnosis
Item
Classification of NSABP Protocol Patient
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C15818 (NCI Thesaurus ObjectClass-2)
C1513905 (UMLS 2011AA ObjectClass-2)
C71104 (NCI Thesaurus ObjectClass-3)
C0008976 (UMLS 2011AA ObjectClass-3)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
Code List
Classification of NSABP Protocol Patient
CL Item
Pregnant Or Post-partum Woman (Pregnant or post-partum woman)
CL Item
Male Partner Of Pregnant Or Post-partum Woman (Male partner of pregnant or post-partum woman)
PersonPriorTherapeuticProcedureMalignantNeoplasmPregnancyText
Item
Cancer Treatment Prior to Pregnancy Diagnosis (Describe most recent cancer treatment prior to pregnancy diagnosis; please include dates of treatment)
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus Property)
C0006826 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
C49236 (NCI Thesaurus Property-3)
C0087111 (UMLS 2011AA Property-3)
C25742 (NCI Thesaurus Property-4)
C0032961 (UMLS 2011AA Property-4)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
PersonPersonalMedicalHistoryPregnancyText
Item
Relevant Past Medical History of Pregnant Individual (e.g., diabetes, surgery, concomitant medications)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
Item Group
Tests & Procedures Relevant To Pregnancy
TherapeuticProcedurePregnancyAssociatedPerformedInd-2
Item
Has the patient had any tests or procedures performed relevant to pregnancy
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
TherapeuticProcedurePregnancyAssociatedPerformedName
Item
Tests/Procedure (Specify)
text
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)
TherapeuticProcedurePregnancyAssociatedPerformedDate
Item
Date of test
date
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Result of test
text
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
Code List
Result of test
CL Item
Abnormal (Abnormal)
C25401 (NCI Thesaurus)
C0205161 (UMLS 2011AA)
C25401 (NCI Thesaurus-3)
C0205161 (UMLS 2011AA-4)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
C14165 (NCI Thesaurus-3)
C0205307 (UMLS 2011AA-4)
TherapeuticProcedurePregnancyAssociatedPerformedAbnormalSpecify
Item
Abnormal (If abnormal, specify)
text
C49236 (NCI Thesaurus ObjectClass)
C0087111 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
C25281 (NCI Thesaurus Property-3)
C0332281 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25401 (NCI Thesaurus ValueDomain-2)
C0205161 (UMLS 2011AA ValueDomain-2)
Item Group
Pregnancy Information
PersonContraceptionUseIndicator
Item
Pregnancy prevention measures
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C37932 (NCI Thesaurus ObjectClass-2)
C0700589 (UMLS 2011AA ObjectClass-2)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
PersonContraceptionUseSpecify
Item
If yes, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C37932 (NCI Thesaurus ObjectClass-2)
C0700589 (UMLS 2011AA ObjectClass-2)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
LastMenstrualCycleOccurrenceDate
Item
Date of last menstrual period
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ObjectClass)
C1517741 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C16838 (NCI Thesaurus ObjectClass-2)
C0025329 (UMLS 2011AA ObjectClass-2)
PregnancyWeekNumberCount
Item
Weeks of gestation when pregnancy first confirmed
float
C25337 (NCI Thesaurus Property)
C0237753 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C0032961 (UMLS 2011AA ObjectClass)
C29844 (NCI Thesaurus Property-2)
C0439230 (UMLS 2011AA Property-2)
PregnancyDeliveryDate
Item
Estimated delivery
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25742 (NCI Thesaurus ObjectClass)
C0032961 (UMLS 2011AA ObjectClass)
C61560 (NCI Thesaurus Property)
Item Group
Pregnancy Status/pregnancy Outcome
Item
Pregnancy Status
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25742 (NCI Thesaurus Property)
C0032961 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
Code List
Pregnancy Status
CL Item
Pregnancy Ongoing (Pregnancy ongoing)
CL Item
Unknown (Unknown)
Item
Pregnancy Outcome
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
Code List
Pregnancy Outcome
CL Item
Delivery (Delivery)
CL Item
Ectopic Pregnancy (Ectopic Pregnancy)
C34945 (NCI Thesaurus)
C0032987 (UMLS 2011AA)
CL Item
Induced Abortion (Induced abortion)
CL Item
Spontaneous Abortion (Spontaneous Abortion)
C34336 (NCI Thesaurus)
C0000786 (UMLS 2011AA)
PersonPregnancyOutcomeDate
Item
Date (Provide date of selected outcome)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25742 (NCI Thesaurus Property-2)
C0032961 (UMLS 2011AA Property-2)
Item Group
Fetal/baby Outcome
PregnancyBirthOutcomeText
Item
Fetal/Baby Outcome
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25742 (NCI Thesaurus ObjectClass)
C0032961 (UMLS 2011AA ObjectClass)
C25155 (NCI Thesaurus Property-2)
C0005615 (UMLS 2011AA Property-2)
Item Group
Footer Module
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

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