Descrizione:

CALGB: 40101 TREATMENT SUMMARY SUBSET FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer NCT00041119 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0

collegamento:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0

Keywords:

26/08/12 26/08/12 -
24/04/15 24/04/15 - Martin Dugas

Caricato su:

24 aprile 2015

DOI:

Per favore, per richiedere un accesso.

Licenza :

Creative Commons BY-NC 3.0 Legacy

Commenti del modello :

Puoi commentare il modello dati qui. Tramite i fumetti nei gruppi di articoli e articoli è possibile aggiungere commenti a quelli in modo specifico.

Torna ai commenti del modello

Commenti del gruppo di articoli per :

Commenti dell'articolo per :

Per scaricare i modelli di dati devi essere registrato. Per favore accesso o registrati GRATIS.

Breast Cancer Treatment CALGB 40101 NCT00041119

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

StudyEvent: CALGB: 40101 TREATMENT SUMMARY SUBSET FORM
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Cycle start date

Cycle end date (M)

Amended data?

Yes

No

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

Completed By (Print or Type Name)

Date Completed (M)

Breast cancer treatment

Current cycle number

BSA

Total dosage for this cycle, Doxorubicin

mg

Total dosage for this cycle, Cyclophosphamide

mg

Total dosage for this cycle, Paclitaxel

mg

Dose adjustments (mark one with an X)

Reduced (1)

Delayed (2)

Reduced And Delayed (3)

Reason for adjustment (Reasons for dose adjustment)

Not Satisfactorily Recovered From Hematologic Toxicity (1)

Grade 3 Or 4 Fatigue (2)

Grade 2 Or 3 Anaphylaxis/hypersensitivity (3)

Grade 3 Or 4 Diarrhea/nausea (4)

7 Più elementi della vista dettagliata

Specify (reason for adjustment) (if applicable)

Ritorna all'inizio della pagina

Similar models

Show recommended models

Si prega di utilizzare questo modulo per feedback, domande e suggerimenti per miglioramenti.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.