Description:

RTOG 1010 EQ-5D Form and Cover Sheet (HP) 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=8669CDC0-3163-DDAC-E040-BB89AD431147

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8669CDC0-3163-DDAC-E040-BB89AD431147

Keywords:
Versions (1) ▾
  1. 7/2/17
Uploaded on:

July 2, 2017

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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RTOG 1010 EQ-5D Form and Cover Sheet (HP)

Details

INSTRUCTIONS: This page must be completed by the medical staff (nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

Unnamed Module 1
Amended data
Unamed Module 2
Time point
Was patient questionnaire completed
Reason Questionnaire was not Completed (PATIENT)
4 more items in the detailed view.
Specify method of completion
Did the patient require any assistance in completing the questionnaire?
Specify the person who assisted the patient
Extent of the assistance
3 more items in the detailed view.
Unamed Module 2
Unnamed Module 3
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