Header
Protocol Number ECOG
text
Patient ID ECOG
Generic drug form
Registration Number
Unnamed2
Patient Initials
Study Number Participating Group
Institution Name
Trial subject ID Participating Group
Unnamed4
Data amended
Data amended date
date
On Treatment Reporting Period
Cycle number
Off Treatment
PersonOff-TreatmentTimePeriodType
Unnamed5
Reporting Period Start Date
Reporting Period End Date
Unnamed6
ConcomitantMedicationCorticosteroidTherapeuticProcedureRelationshipAdverseEventAdministeredInd-2
boolean
CommonTerminologyCriteriaforAdverseEventsVersion4.0LowLevelTermName
ConcomitantMedicationCorticosteroidTherapeuticProcedureRelationshipAdverseEventAdministeredName
AgentAdministeredDose
float
AgentConcomitantAdministrationUOM
ECOGMedicationUOMSpecify
AgentAdministeredFrequency
AgentAdministeredFrequencySpecify
Drug Administration Route
MedicationAdministrationRouteSpecify
Concomitant Medication Start Date
Medication continued
Concomitant Medication End Date
Other Treatment-related Adverse Event
ConcomitantMedicationImmunosuppressantTherapeuticProcedureRelationshipAdverseEventAdministeredInd-2
ConcomitantMedicationImmunosuppressantTherapeuticProcedureRelationshipAdverseEventAdministeredName
ConcomitantMedicationImmunosuppressantTherapeuticProcedureRelationshipAdverseEventAdministeredSpecify
CommonToxicityCriteriaAdverseEventOtherEndocrineSystemSpecify
ConcomitantMedicationHormoneReplacementTherapyTherapeuticProcedureRelationshipAdverseEventAdministeredTherapyInd-2
ConcomitantMedicationHormoneReplacementTherapyTherapeuticProcedureRelationshipAdverseEventAdministeredName
ConcomitantMedicationHormoneReplacementTherapyTherapeuticProcedureRelationshipAdverseEventAdministeredSpecify
Comments
Research Comments
Investigator Signature
Investigator Signature Date