E2905 Hematology Form Lenalidomide With or Without Epoetin Alfa in Treating Patients With Myelodysplastic Syndrome and Anemia NCT00843882 Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
  5. 3/27/15 3/27/15 - Martin Dugas
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March 27, 2015

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Creative Commons BY-NC 3.0 Legacy
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MDS Hematology Form NCT00843882

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

Are data amended
On Treatment Report Period (Step 2 - Choose one x)
Off Treatment Report Period (since registration - Choose one x)
Pre-registration Hematology/chemistry
Test not done (Please mark "X" in Box only if test not done)
CTC Adverse Event Attribution Code (Note: Use the standard CTC criteria, not the BMT-specific CTC criteria.)
AE Expedited report filed? (Check box if yes)
CTC Adverse Event Grade

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