E5202 Adverse Event Form (CTCAE v3.0) NCT00217737 Oxaliplatin, Leucovorin, and Fluorouracil With or Without Bevacizumab in Treating Patients Who Have Undergone Surgery for Stage II Colon Cancer Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  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

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.

E5202 Adverse Event Form (CTCAE v3.0) NCT00217737

INSTRUCTIONS: Complete this form as indicated below and at the end of all protocol therapy. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

ECOG clinical trial administrative data
Are data amended (If yes, please circle amended items in red.)
Patient demographics
On Treatment
On Treatment Report Period (Arm B Only)
Off Treatment
Off Treatment Report Period (since initial registration)
Adverse event assessment
Were adverse events assessed during this report period (cycle)
CTC Adverse Event Term
CTC Adverse Event Attribution Scale
Common Toxicity (Specify site for each event)
Other Adverse Events

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