Description:

CALGB: 40101 TRASTUZUMAB MONITORING FORM NCT00041119 Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD4BCDD9-1BFD-6EE8-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD4BCDD9-1BFD-6EE8-E034-0003BA3F9857

Keywords:

Clinical Trial

Treatment Form

Breast Neoplasms

Uploaded on:

June 21, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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CALGB: 40101 TRASTUZUMAB MONITORING FORM NCT00041119

Details

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.

1 forms

StudyEvent: CALGB: 40101 TRASTUZUMAB MONITORING 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.

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Are data amended

Yes

Patient demographics

Patient Initials

Patient Hospital No

Institution/Affiliate

Participating Group

Participating Group Study No

Participating Group Patient ID

Testing Results

Did the patient receive trastuzumab?

Yes

Trastuzumab Agent Not Administration Specify

Date trastuzumab started

Date trastuzumab discontinued

Reason for ending trastuzumab treatment

Completed Per Protocol Criteria (Completed per protocol criteria)

Cardiac Adverse Event (Cardiac adverse event)

Other Cardiac Adverse Event (Other cardiac adverse event)

Non-cardiac Adverse Event (Non-cardiac adverse event)

Other (Other)

Other, specify

Footer

Completed by

Date Form Completed

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