English

INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 forms  
  1. StudyEvent: FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT
    1. INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Header
Description

Header

RTOG Study
Description

RTOGStudy

Data type

text

Case #
Description

Case#

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Institution No.
Description

NCIInstitutionNumber

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

AMENDED DATA
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
DATE FROM (Q2)
Description

IntervalReportFromDate

Data type

date

Patient data
Description

Patient data

PATIENT'S VITAL STATUS
Description

PATIENT'S VITAL STATUS

Data type

text

Alias
UMLS CUI-1
C1148433
DATE OF LAST CONTACT OR DEATH
Description

DeathDate/LastContactDate

Data type

date

CAUSE OF DEATH
Description

DeathReason

Data type

text

Due to other cause, specify (cause of death)
Description

PrimaryCauseDeathOtherReasonSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C25251
UMLS 2011AA ObjectClass-2
C0205225
NCI Metathesaurus ObjectClass
C0007465
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property-2
C25365
UMLS 2011AA Property-2
C0678257
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
Description

CancerFollow-upStatusInd

Data type

text

DATE OF LAST CLINICAL ASSESSMENT
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PERFORMANCE STATUS (ZUBROD)
Description

PerformanceStatus

Data type

text

Follow-up PSA Value(s)
Description

Follow-upPSAValue(s)

Data type

text

Date of PSA Assessment(s)
Description

AssessmentDate

Data type

date

HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
Description

HASTHEPATIENTHADAPROSTATEBIOPSYSINCESUBMISSIONOFTHELASTFOLLOWUPFORM?

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ValueDomain-2
C25180
Biopsy Date
Description

Biopsy Date

Data type

date

Alias
UMLS CUI-1
C0005558
UMLS CUI-2
C0011008
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Description

ProgressionInd

Data type

boolean

Alias
UMLS CUI-1
C0242656
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Description

ProgressionInd,Biochemical

Data type

text

DATE OF FIRST BIOCHEMICAL PROGRESSION
Description

ProgressionDate,FirstBiochemical

Data type

date

PSA VALUE AT PROGRESSION
Description

ProgressionPSAValue

Data type

float

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Description

ProgressionInd,FirstLocal-Regional

Data type

text

Date of First Local-Regional Progression
Description

ProgressionDate,FirstLocal-Regional

Data type

date

Site(s) of Local/Regional Progression
Description

ProgressionSite(s),FirstLocal-Regional

Data type

text

WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
Description

AssessmentType

Data type

text

Other, specify (method used to determine distant progression)
Description

AssessmentType,Specify

Data type

text

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
Description

ProgressionInd,FirstDistant

Data type

text

Date of First Distant Progression
Description

ProgressionDate,FirstDistant

Data type

date

Site(s) of First Distant Progression
Description

ProgressionSite,FirstDistant

Data type

text

New Primary Site
Description

NewPrimarySite

Data type

text

New Primary Cancer Date
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify (new primary site)
Description

Specify(newprimarysite)

Data type

text

Non-Protocol Therapy
Description

Non-Protocol Therapy

Alias
UMLS CUI-1
C1518384
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
Description

Non-ProtocolTherapyInd

Data type

text

Non-Protocol Therapy Type
Description

Non-ProtocolTherapyAdministeredType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Radiation to other sites, specify (non-protocol therapy type)
Description

Radiationtoothersites,specify(non-protocoltherapytype)

Data type

text

Other, specify (non-protocol therapy type)
Description

Non-ProtocolTherapyType

Data type

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass-2
C2167
UMLS 2011AA ObjectClass-2
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Surgical procedure related to previous RT, specify (non-protocol therapy type)
Description

SurgicalprocedurerelatedtopreviousRT,specify(non-protocoltherapytype)

Data type

text

Complementary Alternative Medicine, specify (non-protocol therapy type)
Description

ComplementaryAlternativeMedicine,specify(non-protocoltherapytype)

Data type

text

Date of first non-protocol therapy
Description

Non-ProtocolTherapyDate,First

Data type

date

Specify (non-protocol prostate cancer therapy) (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
Description

Specify(non-protocolprostatecancertherapy)

Data type

text

Adverse event
Description

Adverse event

Alias
UMLS CUI-1
C0877248
NEW OR CONTINUING TOXICITY (>Severity Grade 3) SINCE THE LAST REPORT? (For severe toxicity grade > 3 observed during the report period, provide a date of onset, assign attribution, and describe toxicity and treatment given. Do not list a toxicity code more than once in the reporting section of this form. If toxicity cannot b)
Description

NEWORCONTINUINGTOXICITY(>SeverityGrade3)SINCETHELASTREPORT?

Data type

boolean

Alias
UMLS CUI-1
C1519275
UMLS CUI-2
C3537125
IMT CODE ADVERSE EVENT BASED ON CTEP TOXICITY TERM
Description

IMTCODEADVERSEEVENTBASEDONCTEPTOXICITYTERM

Data type

text

CTC ADVERSE EVENT TERM
Description

CTCAdverseEventTerm

Data type

text

Alias
UMLS CUI-1
C1516728
UMLS CUI-2
C2826934
COMMON TOXICITY GENERAL CATEGORY
Description

CTCAdverseEventCategory

Data type

text

CTC ADVERSE EVENT GRADE
Description

CTCAdverseEventGrade

Data type

text

Alias
UMLS CUI-1
C2985911
CTC ADVERSE EVENT ONSET DATE (GRADE > OR = 3)
Description

CTCAdverseEventReportBeginDate

Data type

date

CTC ADVERSE EVENT ATTRIBUTION CODE
Description

CTCAdverseEventAttributionCode

Data type

text

Other cause, specify (CTC Adverse Event Attribution Code)
Description

CTCAdverseEventTerm,Other

Data type

text

SPECIFY
Description

Specify

Data type

text

COMMENTS
Description

Comments

Data type

text

SIGNATURE
Description

SignatureofPersonCompletingThisForm

Data type

text

DATE
Description

FormCompletionDate,Original

Data type

date

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Similar models

INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 forms
  1. StudyEvent: FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT
    1. INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
AmendedDataInd
Item
AMENDED DATA
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IntervalReportFromDate
Item
DATE FROM (Q2)
date
Item Group
Item
PATIENT'S VITAL STATUS
text
C1148433 (UMLS CUI-1)
CL.1
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
C2584946 (UMLS CUI-1)
CL Item
Dead (Dead)
C0011065 (UMLS CUI-1)
DeathDate/LastContactDate
Item
DATE OF LAST CONTACT OR DEATH
date
Item
CAUSE OF DEATH
text
CL.2
Code List
CAUSE OF DEATH
CL Item
N/A (N/A)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PrimaryCauseDeathOtherReasonSpecify
Item
Due to other cause, specify (cause of death)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus ObjectClass-2)
C0205225 (UMLS 2011AA ObjectClass-2)
C0007465 (NCI Metathesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
text
CL.3
Code List
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
Follow-upPSAValue(s)
Item
Follow-up PSA Value(s)
text
AssessmentDate
Item
Date of PSA Assessment(s)
date
Prostate biopsy since last follow-up
Item
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
boolean
C25704 (NCI Thesaurus ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
BiopsyDate
Item
Biopsy Date
date
C0005558 (UMLS CUI-1)
C0011008 (UMLS CUI-2)
Progression
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
boolean
C0242656 (UMLS CUI-1)
Item
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
CL.6
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstBiochemical
Item
DATE OF FIRST BIOCHEMICAL PROGRESSION
date
ProgressionPSAValue
Item
PSA VALUE AT PROGRESSION
float
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
CL.7
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstLocal-Regional
Item
Date of First Local-Regional Progression
date
ProgressionSite(s),FirstLocal-Regional
Item
Site(s) of Local/Regional Progression
text
Item
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
text
CL.10
Code List
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
CL Item
Clinical Examination (Physical exam)
CL Item
Pathologic (Pathologic)
CL Item
Radiographic (Radiographic)
CL Item
Nuclear scan (Nuclear scan)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AssessmentType,Specify
Item
Other, specify (method used to determine distant progression)
text
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
text
CL.9
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Date of First Distant Progression
date
ProgressionSite,FirstDistant
Item
Site(s) of First Distant Progression
text
NewPrimarySite
Item
New Primary Site
text
NewPrimaryCancerDate
Item
New Primary Cancer Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Specify(newprimarysite)
Item
Specify (new primary site)
text
Item Group
C1518384 (UMLS CUI-1)
Item
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
text
CL.11
Code List
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Therapy Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.12
Code List
Non-Protocol Therapy Type
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Radiation To Pelvis (Radiation to pelvis)
CL Item
Radiation To Other Sites, Specify (Radiation to other sites, specify)
CL Item
Surgery (Surgery)
C17173 (NCI Thesaurus)
C0038894 (UMLS 2011AA)
CL Item
Chemotherapy (Chemotherapy)
C15632 (NCI Thesaurus)
C0392920 (UMLS 2011AA)
CL Item
Hormones (Hormones)
CL Item
Other Specify (Other, specify)
CL Item
Surgical Procedure Related To Previous Rt, Specify (Surgical procedure related to previous RT, specify)
CL Item
Complementary Alternative Medicine, Specify (Complementary Alternative Medicine, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Radiationtoothersites,specify(non-protocoltherapytype)
Item
Radiation to other sites, specify (non-protocol therapy type)
text
Non-ProtocolTherapyType
Item
Other, specify (non-protocol therapy type)
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass-2)
C1443775 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
SurgicalprocedurerelatedtopreviousRT,specify(non-protocoltherapytype)
Item
Surgical procedure related to previous RT, specify (non-protocol therapy type)
text
ComplementaryAlternativeMedicine,specify(non-protocoltherapytype)
Item
Complementary Alternative Medicine, specify (non-protocol therapy type)
text
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Specify(non-protocolprostatecancertherapy)
Item
Specify (non-protocol prostate cancer therapy) (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
text
Item Group
C0877248 (UMLS CUI-1)
Toxicity grade 3 or more
Item
NEW OR CONTINUING TOXICITY (>Severity Grade 3) SINCE THE LAST REPORT? (For severe toxicity grade > 3 observed during the report period, provide a date of onset, assign attribution, and describe toxicity and treatment given. Do not list a toxicity code more than once in the reporting section of this form. If toxicity cannot b)
boolean
C1519275 (UMLS CUI-1)
C3537125 (UMLS CUI-2)
IMT code adverse event
Item
IMT CODE ADVERSE EVENT BASED ON CTEP TOXICITY TERM
text
CTCAdverseEventTerm
Item
CTC ADVERSE EVENT TERM
text
C1516728 (UMLS CUI-1)
C2826934 (UMLS CUI-2)
Item
COMMON TOXICITY GENERAL CATEGORY
text
CL.15
Code List
COMMON TOXICITY GENERAL CATEGORY
CL Item
Allergy/Immunology (Allergy/Immunology)
CL Item
Auditory/Hearing (Auditory/Hearing)
CL Item
Blood/Bone marrow (Blood/Bone marrow)
CL Item
Cardiovascular (Arrhythmia) (Cardiovascular (Arrhythmia))
CL Item
Cardiovascular (General) (Cardiovascular (General))
CL Item
Coagulation (Coagulation)
CL Item
Constitutional Symptoms (Constitutional Symptoms)
CL Item
Dermatology/Skin (Dermatology/Skin)
CL Item
Endocrine (Endocrine)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Hepatic (Hepatic)
CL Item
Infection Febrile Neutropenia (Infection Febrile Neutropenia)
CL Item
Lymphatics (Lymphatics)
CL Item
Metabolic/Laboratory (Metabolic/Laboratory)
CL Item
Musculoskeletal (Musculoskeletal)
CL Item
Neurology (Neurology)
CL Item
Ocular/Visual (Ocular/Visual)
CL Item
Pain (Pain)
CL Item
Pulmonary (Pulmonary)
CL Item
Renal/Genitourinary (Renal/Genitourinary)
CL Item
Second Malignancy (Second Malignancy)
CL Item
Sexual/Reproductive Function (Sexual/Reproductive Function)
CL Item
Syndromes (Syndromes)
CTCAdverseEventGrade
Item
CTC ADVERSE EVENT GRADE
text
C2985911 (UMLS CUI-1)
CTCAdverseEventReportBeginDate
Item
CTC ADVERSE EVENT ONSET DATE (GRADE > OR = 3)
date
Item
CTC ADVERSE EVENT ATTRIBUTION CODE
text
CL.16
Code List
CTC ADVERSE EVENT ATTRIBUTION CODE
CL Item
Radiotherapy only (Radiotherapy only)
CL Item
Chemotherapy only (Chemotherapy only)
CL Item
Combined modality (Combined modality)
CL Item
Tumor and Rx (Tumor and Rx)
CL Item
Hormones (Hormones)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
CTCAdverseEventTerm,Other
Item
Other cause, specify (CTC Adverse Event Attribution Code)
text
Specify
Item
SPECIFY
text
Comments
Item
COMMENTS
text
SignatureofPersonCompletingThisForm
Item
SIGNATURE
text
FormCompletionDate,Original
Item
DATE
date
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