Description:

E1305 Long-Term Follow-up Form NCT00588770 Chemotherapy With or Without Bevacizumab in Treating Patients With Recurrent or Metastatic Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1A097748-4562-2BCB-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1A097748-4562-2BCB-E044-0003BA3F9857

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Versions (3) ▾
  1. 9/19/12
  2. 1/8/15
  3. 6/8/15
Uploaded on:

June 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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E1305 Long-Term Follow-up Form NCT00588770

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

Header
Patient demographics
Off protocol treatment period
Off Treatment Report Period (since initial registration)
Data amendment
Vital Status
Patient 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 MDS been diagnosed that has not been previously reported
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?
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 previsouly reported - NOTE: Only the first occurrence of non-protocol therapy should be reported)
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