Description:

CALGB: TRASTUZUMAB MONITORING FORM NCT00024102 Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0DF41E5E-5CC3-5A4A-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0DF41E5E-5CC3-5A4A-E044-0003BA3F9857

Uploaded on:

July 3, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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CALGB: TRASTUZUMAB MONITORING FORM NCT00024102

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. 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.

1 forms

StudyEvent: CALGB: 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. 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

Amended data?

Yes (Yes)

Patient demographics

Patient Initials (Last, First Middle)

Participating Group

Patient Hospital No.

Participating Group Study No.

Institution/Affiliate

Participating Group Patient ID

Testing Results

Did the patient receive any Herceptin treatment?

Yes

No, specify reason

Date trastuzumab started (mm/dd/yyyy)

Date trastuzumab discontinued (mm/dd/yyyy)

Reason for ending trastuzumab treatment (Mark one with an X)

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

Form completed by

Completed by

Date Form Completed

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