Description:

E1105 Adverse Event Form (CTCAE v3) 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=1722503D-5400-666B-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1722503D-5400-666B-E044-0003BA3F9857
Keywords:
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
  5. 7/8/15 7/8/15 -
Uploaded on:

July 8, 2015

DOI:
To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

E1105 Adverse Event Form (CTCAE v3) NCT00520975

INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle = 3 weeks), and at required follow-ups if specified by the Long-Term Follow-Up Form (to report late adverse events).

ECOG clinical trial administrative data
Patient demographics
Data amendment
On Treatment
On Treatment Report Period (since start of treatment)
On Treatment Report Period (since start of treatment)
Off Treatment
Off Treatment Report Period (since registration)
Adverse event report
Were adverse events assessed during this report period
Blood/bone Marrow - Labs
CTC Adverse Event Term
CTC Adverse Event Attribution Code
Was this attributed to investigational protocol treatment
II. NON-HEMATOLOGIC
CTC Adverse Event Term
CTC Adverse Event Short Name (Specify site for each event)
CTC Adverse Event Attribution Code
CTC Adverse Event Attribution Code
Was this attributed to investigational protocol treatment
Was this attributed to investigational protocol treatment
III. NON-HEMATOLOGIC
CTC Adverse Event Term
CTC Adverse Event Attribution Code
Was this attributed to investigational protocol treatment
Other Adverse Events
CTC Adverse Event Attribution Code
Was this attributed to investigational protocol treatment
V. INFECTIONS
CTC Adverse Event Short Name (Specify site for each event)
CTC Adverse Event Attribution Code
Was this attributed to investigational protocol treatment
Comments

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial