Informatie: Dit is niet de actueelste versie van het datamodel. Een versieoverzicht vindt u links onder Versies. De actueelste versie vindt u hier.

Beschrijving:

CALGB: 40101 TRASTUZUMAB MONITORING FORM 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

Trefwoorden:

26-08-12 26-08-12 -
09-01-15 09-01-15 - Martin Dugas
21-06-15 21-06-15 -

Geüploaded op:

9 januari 2015

DOI:

Voor een aanvraag inloggen.

Licentie :

Creative Commons BY-NC 3.0 Legacy

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren

Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Breast Cancer NCT00041119 Treatment - CALGB: 40101 TRASTUZUMAB MONITORING FORM - 2322062v1.0

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.

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

No

Unnamed2

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

No

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

Terug naar het begin van de pagina

Similar models

Show recommended models

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

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.