Patient demographics
Patient Initials
text
Participating Group
text
Medical Record Number
text
Study Number Participating Group
text
Institution Name
text
Trial subject ID Participating Group
text
Hospitalization And Emergency Room Data
HospitalizationReportPeriodInd-2
boolean
TreatingHospitalName
text
HospitalIntensiveCareUnitAdmissionDayCount
float
HospitalAdmissionDate
date
InpatientDischargeDate
date
Outpatient Data
OutpatientTreatmentReportingPeriodInd-2
boolean
OtherTreatmentOutpatientVisitCount
float
Evaluation method
text
Evaluation method, specify
text
AssessmentPerformedCount
float
Operating Room Data
Procedure Performed Type
text
PrimarySurgicalProcedurePerformedText
text
ProcedurePerformedCount
float
Non-protocol Chemotherapy Data
Non-protocolChemotherapyAdministeredInd-3
boolean
Agent
text
AgentCourseCount
float
Person Completing Form
text
Form Completion Date
date