Description:

CALGB: 80203 ADVERSE EVENT FORM NCT00077233 Fluorouracil and Leucovorin Plus Either Irinotecan or Oxaliplatin With or Without Cetuximab in Treating Patients With Previously Untreated Metastatic Adenocarcinoma of the Colon or Rectum Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B4C3B499-D669-0736-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B4C3B499-D669-0736-E034-0003BA12F5E7

Keywords:

Colorectal Neoplasms

Clinical Trial

Adverse event

Uploaded on:

July 8, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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CALGB: 80203 ADVERSE EVENT FORM NCT00077233

Details

No Instruction available.

1 forms

StudyEvent: CALGB: 80203 ADVERSE EVENT FORM
1. No Instruction available.

Header

CALGB Form

CALGB Study No.

CALGB Patient ID

From

Are data amended?

Yes

Patient demographics

Patient Intitials

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

AER/ADR filed?

Was an AER/ADR filed with Central Office based on an event reported below?

Yes

Expected Adverse Events

MedDRA Code

Name

Grade

Treatment Related

Unrelated (unrelated to treatment)

Unlikely (unlikely to be related to treatment)

Possible (possibly related to treatment)

Probable (probably related to treatment)

Definite (definitely related to treatment)

Completed By (Print or Type Name)

Date form completed (M)

Ccrr Module For Calgb: 80203 Adverse Event Form

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