Module 1
ProtocolRTOGIdentifierNumber
text
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
InstitutionName
InstitutionIdentifierNumber
PatientInitialsName
PatientRadiationTherapyOncologyGroupIdentifierNumber
DataAmendedInd-3
Assessment
PatientHeightMeasurement
double
PatientWeightMeasurement
PersonBodySurfaceAreaValue
AgentElevatedCreatinineDoseModificationInd-2
DoseModificationInd-2
Unnamed 3
AgentName
AgentBeginDate
date
AgentEndDate
AgentTotalDoseCount
AgentAdministeredDose
AgentDoseAdministeredDate
CumulativeAgentTotalDose
DoseModificationInd
Off-treatmentReason
AlternativeTherapyAdministeredSpecify
Off-treatmentComplicatingReasonSpecify
Off-treatmentReasonSpecify
Protocol Specific Adverse Event Evaluation
TreatmentRelatedAdverseEventReportInd-3
MedDRACode
AdverseEventCommonTerminologyforAdverseEventsVersion4TermName
CommonToxicityCriteriaAdverseEventGrade
CTCAdverseEventReportBeginDate
CTCAdverseEventAttributionScale
SeriousAdverseEventReportInd-3
Unnamed3
LaboratoryProcedureResultUnitofMeasureType
LaboratoryProcedureHemoglobinResultSpecifiedValue
LaboratoryProcedureHematocritOutcomePercentageValue
LaboratoryProcedureLeukocyteResultUnspecifiedValue
LaboratoryProcedurePlateletResultSpecifiedValue
LaboratoryProcedureNeutrophilResultPercentageValue
LaboratoryProcedureNeutrophilResultTotalValue
LaboratoryProcedureSodiumElectrolytesOutcomeSpecifiedValue
LaboratoryProcedurePotassiumElectrolytesOutcomeSpecifiedValue
LaboratoryProcedureChlorideIonElectrolytesOutcomeSpecifiedValue
LaboratoryProcedureBloodUreaNitrogenResultUnspecifiedValue
LaboratoryProcedureCreatinineResultSpecifiedValue
LaboratoryProcedureCreatinineClearanceOutcomeValue
LaboratoryProcedureTotalBilirubinResultSpecifiedValue
LaboratoryProcedureAlkalinePhosphataseResultValue
LaboratoryProcedureLactateDehydrogenaseResultSpecifiedValue
LaboratoryProcedureSerumGlutamicOxaloaceticTransferaseResultSpecifiedValue
LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultUnspecifiedValue
LaboratoryProcedureTotalSerumProteinOutcomeUnspecifiedValue
LaboratoryProcedureTotalUrineProteinOutcomeUnspecifiedValue
LaboratoryProcedureAlbuminResultSpecifiedValue
LaboratoryProcedureUricAcidResultSpecifiedValue
LaboratoryProcedureCalciumElectrolytesOutcomeValue
LaboratoryProcedureGlucoseElectrolytesOutcomeUnspecifiedValue
LaboratoryProcedureMagnesiumResultSpecifiedValue
LaboratoryProcedurePerformedSpecify
LaboratoryProcedurePerformedValue
Unnamed Module 4
ResearchCommentsText
InvestigatorSignatureText
InvestigatorSignatureDate