Description:

CALGB: 10603 Lab Results - Thyroid Function Tests NCT00651261 Daunorubicin, Cytarabine, and Midostaurin in Treating Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=623366AE-B316-EBAB-E040-BB89AD43128A

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=623366AE-B316-EBAB-E040-BB89AD43128A

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Uploaded on:

June 8, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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CALGB: 10603 Lab Results - Thyroid Function Tests DRKS00003845 NCT00651261

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

StudyEvent: CALGB: 10603 Lab Results - Thyroid Function Tests
1. 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

Header

CALGB Form

CALGB Study No.

CALGB Patient ID

Reporting Period Start Date (MM DD YYYY)

Reporting Period End Date (MM DD YYYY)

Are data amended

Yes

No

Patient demographics

Patient Initials (Last, First Middle)

Patient Hospital No.

Institution/Affiliate

Participating Group

Participating Group Study No.

Participating Group Patient ID

Lab

Name of Laboratory

Laboratory ID (provided by CALGB)

Treatment Phase

Baseline (Baseline)

Consolidation #1 (Consolidation #1)

Consolidation #2 (Consolidation #2)

Consolidation #3 (Consolidation #3)

5 more items in the detailed view.

Lab collection time point (Mark one with an X)

A Regularly Scheduled Time Point (A regularly scheduled time point)

An Additional Time Point (An additional time point)

T4 (Thyroxine)

TSH (Thyroid Stimulating Hormone/Thyrotropin)

Overall Response

Completed by (print or type name)

Date Form Completed (MM DD YYYY)

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