E2905 Vital Status Form Source Form: NCI FormBuilder:


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  3. 6/8/15
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June 8, 2015

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Leukemia - E2905 Vital Status Form

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

ECOG clinical trial administrative data
Data amendment
Off protocol treatment period
Off Treatment Report Period (since initial registration)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Section II - Reporting Period
Notice Of New Primary (including Second Colon Primary)
Has a new primary cancer or myelodysplastic syndrome been diagnosed that has not been previously reported (MDS)
Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
Has the patient developed a first progression (or relapse) that has not been previously reported? (Notice of Progression)
Did a physician make a formal diagnosis of progressive disease?
Adverse Events
Has the patient experienced any severe long term toxicity that has not been previously reported (prior to diagnosis of progression/relapse)
Non-protocol Therapy
Has the patient received any non-protocol cancer therapy prior to first progression (not previously reported)

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