Description:

NSABP PROTOCOL B-39: REGISTRATION FORM - B-39 Form A NCT00103181 Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6E4EDBC-FF93-23A2-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6E4EDBC-FF93-23A2-E034-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 7/3/15
Uploaded on:

July 3, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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NSABP PROTOCOL B-39: REGISTRATION FORM - B-39 Form A NCT00103181

Provide the code number of the credentialed facility where the patient will receive her radiation treatment.

NSABP REGISTRATION FORM
Race (more than one may be marked)
Method of Payment (mark primary method only)
Ethnicity
Country of Residence (if not USA)
Your blood and tissues samples may be kept by the NSABP for use in future research to learn about, prevent, detect, or treat cancer.
Your blood and tissue samples may be used for research about other health problems (for example: causes of heart disease, osteoporosis, diabetes).
Your study doctor (or someone he or she chooses) may contact you in the future to ask you to take part in more research.
cm
Kg
Disease Stage
Menopausal status
Hormonal Status
Intention to Receive Chemotherapy
Footer module
PBI Technique
Certification Of Eligibility:
In the opinion of the investigator, is the patient eligible?

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