Description:

NCT01196390 RTOG 1010 Maintenance Systemic Treatment Summary Form (SF) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=870A090F-64E8-A152-E040-BB89AD430551

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=870A090F-64E8-A152-E040-BB89AD430551
Keywords:
Versions (5)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - 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.

Back to model comments
Itemgroup comments for :

Item comments for :

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

NCT01196390 RTOG 1010 Maintenance Systemic Treatment Summary Form (SF)

English
Details

INSTRUCTIONS: Form is submitted 1 week after completion or termination of cycle1-5, cycle 6-10 and cycle 11-13, for a total of 3 submissions. All 3 pages of the form must be submitted. Dates are mm-dd-yyyy unless otherwise specified

1 forms  
Header Module
Amended Data
Assessment
cm
Kg
m2
Reporting Period (WHICH CYCLE IS BEING REPORTED)
Treatment Summary
Dose Modification (Change)
Reason Treatment Ended
5 more items in the detailed view.
Therapy Modification
Toxicities
Was a MUGA/Echocardiogram Performed During This Report Period
Incipient CHF (If yes, did the patient experience defined as asymptomatic >20% decrease in LVEF or a decrease of LVEF >10% below the institutions lower limit of normal and required treatment according to institutional guidelines)
LVEF Status (If a MUGA/echocardiogram was performed during this report period)
3 more items in the detailed view.
Grade 3 or 4 Restrictive Cardiomyopathy (IF ANY ANSWERED YES, REPORT COMPLETELY IN Q#12)
Protocol Specific Adverse Event Evaluation
Any adverse events
CTC AE Grade
CTC AE Attribution Code
SAE report submitted
Comments
Back to the top of the page

Similar models

Contact

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

Fields marked with * are required.

Help

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