Description:

CALGB 90601: Eligibility Checklist NCT00942331 Gemcitabine Hydrochloride and Cisplatin With or Without Bevacizumab in Treating Patients With Advanced Urinary Tract Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657F334E-CCEE-8AE9-E040-BB89AD43469A

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657F334E-CCEE-8AE9-E040-BB89AD43469A

Keywords:

Clinical Trial

Eligibility Determination

Urinary Bladder Neoplasms

Versions (3) ▾

8/26/12
1/9/15
6/21/15

Uploaded on:

June 21, 2015

DOI:

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License:

Creative Commons BY-NC 3.0 Legacy

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CALGB 90601: Eligibility Checklist NCT00942331

Details

INSTRUCTIONS: Complete all information on this form. Submit within one week of registration along with the On-Study Form.

StudyEvent: CALGB 90601: Eligibility Checklist
1. INSTRUCTIONS: Complete all information on this form. Submit within one week of registration along with the On-Study Form.

Header

CALGB Study No

CALGB Patient ID

Patient demographics

Patient Initials (Last, First Middle)

Patient Hospital No.

Institution/Affiliate

Participating Group

Participating Group Study No.

Participating Group Patient ID

Eligibility Criteria

Patient eligibility

>= 4 Weeks From Any Intravesical Therapy (>= 4 weeks from any intravesical therapy)

>= 4 Weeks Since Any Radiation Therapy (including Palliative) Or Major Surgery And Fully Recovered (>= 4 weeks since any radiation therapy (including palliative) or major surgery and fully recovered)

Age >= 18 Yrs (Age >= 18 yrs)

Anc >= 1500/mcl (ANC >= 1500/mcl)

Ast <= 2.0 X Uln (AST <= 2.0 x ULN)

21 more items in the detailed view.

Footer Module

Completed by (Last name, First name)

Date Form Completed (MM DD YYYY)

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