ID

8101

Descrição

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

Palavras-chave

Clinical Trial

Treatment Form

D001943

26/08/2012 26/08/2012 -
09/01/2015 09/01/2015 - Martin Dugas
21/06/2015 21/06/2015 -

Transferido a

9 de janeiro de 2015

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy

Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo

Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

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

Detalhes

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 Formulários

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

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

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

Voltar ao início da página

Similar models

Show recommended models

ID