Description:

E1105 Assessment Compliance Form NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17223B5E-5840-64C8-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17223B5E-5840-64C8-E044-0003BA3F9857
Keywords:
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 6/8/15 6/8/15 -
Uploaded on:

June 8, 2015

DOI:
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License :
Creative Commons BY-NC 3.0 Legacy
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E1105 Assessment Compliance Form NCT00520975

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files.

Header
Patient demographics
Reporting Period
On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
Data amendment
Section I
Section Ii - Assessments Not Completed
Was the Assessment Form completed?
Section Ii - Assessments Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Other
Section Ii - Assessments Not Completed
Patient refusal
Unable to accomodate disability or language needs
Patient did not show up in clinic/office
Staff unavailable
Patient not given form by staff
Patient too ill
Patient expired
Assessment not required per protocol
Staff thought patient too ill
Other
Section Iii - Assessment Completed
Was Assessment self-administered?
How Was The Patient Assisted
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
How Was The Patient Assisted
Were the questions read aloud to patient
Did the patient require clarification of questions or instructions
Did the patient require other assistance
Were the forms completed independently by another person
What Was The Reason For Assistance
Did the patient have a language difficulty (questions needed to tbe translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Other
What Was The Reason For Assistance
Did the patient have a language difficulty (questions needed to tbe translated)
Did the patient have a literacy difficulty (patient could not read well enough)
Was the patient disabled
Were the forms completed via a telephone interview
Other
Who Assisted Or Completed Assessment
Staff
Family
Friend
Other
Who Assisted Or Completed Assessment
Staff
Family
Friend
Other
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