Description:

CALGB: 49903 ADVANCED FOLLOW-UP FORM NCT00053339 Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D2007-5070-476F-E034-0003BA0B1A09

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D2007-5070-476F-E034-0003BA0B1A09

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 5/22/15
  3. 6/3/15
Uploaded on:

June 3, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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CALGB: 49903 ADVANCED FOLLOW-UP FORM NCT00053339

Details

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

CALGB Information
Amended data?
Patient clinical trial data
Cancer follow up
Vital Status (mark one with an X)
cause of death (mark one with an X)
Has patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Has the patient achieved a response? (mark one with an X)
Did the patient develop a first progression (or relapse) that has not been previously reported?
Non-protocol Therapy
Is the patient receiving any non-protocol cancer therapy not previously reported?
Non-protocol therapy
Ccrr Module For Calgb: 49903 Advanced Follow-up Form
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