INSTRUCTIONS: Complete this form as indicated below and at the end of all protocol therapy. Submit original to the ECOG Coordinating Center. Keep a copy for your files.
INSTRUCTIONS: Complete this form as indicated below and at the end of all protocol therapy. Submit original to the ECOG Coordinating Center. Keep a copy for your files.
On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)
On Treatment Report Period (Choose one x - NOTE: If the duration of the final treatment period is less than the report period intervals listed below, choose the next highest report period.)
Were adverse events assessed during this report period
CL Item
Not assessed (0)
C3846720 (UMLS CUI-1)
CL Item
Yes, But No Reportable Adverse Events Occurred (1)
C1963761 (UMLS CUI-1)
CL Item
Yes, And Reportable Adverse Events Occurred (2)
C0877248 (UMLS CUI-1)
Adverse Event Start Date
Item
CTC Adverse Event Report Begin Date (For the dates below, record the start and end dates of the time period within current report period in which patient was assessed for adverse events. - mm/dd/yyyy)
CTC Adverse Event Report End Date (For the dates below, record the start and end dates of the time period within current report period in which patient was assessed for adverse events. - mm/dd/yyyy)