Description:

E2905 Hematology Form Lenalidomide With or Without Epoetin Alfa in Treating Patients With Myelodysplastic Syndrome and Anemia NCT00843882 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11427DB4-3795-240D-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11427DB4-3795-240D-E044-0003BA3F9857
Keywords:
  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
Uploaded on:

March 27, 2015

DOI:
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License :
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

Header
Are data amended
ON/Off TREATMENT
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)
/mm^3
/mm^3
1000/uL
%
1000/uL
mg/dL
g/dL
g/dL
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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