Beschrijving:

PACCT-1 TAILORx Virtual Frozen Tissue Bank Form Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1CCEFBDC-5252-021E-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1CCEFBDC-5252-021E-E044-0003BA3F9857

Trefwoorden:

D016430

C50.9

Pathology

26-08-12 26-08-12 -
09-01-15 09-01-15 - Martin Dugas

Geüploaded op:

9 januari 2015

DOI:

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Licentie :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00310180 Pathology - PACCT-1 TAILORx Virtual Frozen Tissue Bank Form - 2518507v1.0

Details

Instructions: Submit within 4 weeks of registration/randomization, if patient provides consent for future research and is available. Submit this form to the ECOG PCO only. Frozen tissue will be retained at the local site until requested by the ECOG PCO.

1 Formulieren

StudyEvent: PACCT-1 TAILORx Virtual Frozen Tissue Bank Form
1. Instructions: Submit within 4 weeks of registration/randomization, if patient provides consent for future research and is available. Submit this form to the ECOG PCO only. Frozen tissue will be retained at the local site until requested by the ECOG PCO.

Header

ECOG Protocol Number

ECOG Patient ID

DCI Name

Registration Step Number

Reporting Period

Baseline (Baseline)

Patient Information

Patient Initials (Last First Middle)

Investigator's First Name

Investigator's Last Name

Registered Investigator (NCI Investigator #)

Frozen Tissue Information

Patient Medical Record Number

Collection Date (Specimen for frozen tissue m/d/y)

Pathology Institution Name (at which frozen tissue is held)

Dept/Building (Address:)

Street Name and Number

City

State/Province

Country

Postal Code

Footer Module

Investigator Signature

Person Completing Form, Last Name

Person Completing Form, First Name

Form Completion Date, Original (m/d/y)

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