Description:

IBCSG Long Term Follow-Up Death Form (18-LTF-Death) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C95-8540-E040-BB89AD4303DD

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C95-8540-E040-BB89AD4303DD

Keywords:

Clinical Trial

Death

Breast Neoplasms

Versions (2) ▾

8/26/12
6/12/17

Uploaded on:

June 12, 2017

DOI:

No DOI assigned. To request one pleaselog in.

License:

Creative Commons BY-NC 3.0

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IBCSG Long Term Follow-Up Death Form (18-LTF-Death)

Details

Instructions: This form is to be completed if the patient died during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

StudyEvent: IBCSG Long Term Follow-Up Death Form (18-LTF-Death)
1. Instructions: This form is to be completed if the patient died during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

Header Module

Visit number

IBCSG Patient ID

IBCSG Study No.

Randomization No.

Institution Code Number

Institution Name

Long Term Follow-up Death

Date of Death

day month year

Disease status at time of death (or last known report)

No Recurrence Or Second Non-breast Primary Malignancy (1)

Local Recurrence (2)

Regional Recurrence (3)

Distant Metastasis (4)

Primary cause of death

Progression Of Underlying Breast Cancer (1)

Endometrial Cancer (2)

Myocardial Infarction (3)

Stroke (4)

Thromboembolic Event (5)

4 more items in the detailed view.

Other cause of death

Footer Module

Investigator/Designee Signature

Date