Description:

CALGB: OFF TREATMENT NOTICE Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Leukemia NCT00085124 Off Treatment - CALGB: OFF TREATMENT NOTICE - 2076876v3.0 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F9FE-3D25-514D-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B229F9FE-3D25-514D-E034-0003BA12F5E7

Keywords:

Leukemia, Myeloid, Acute

AML

Clinical Trial

Off-Treatment

9/19/12 9/19/12 -
7/21/17 7/21/17 - Martin Dugas

Uploaded on:

July 21, 2017

DOI:

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License :

Creative Commons BY-NC 3.0

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AML Daunorubicin Cytarabine NCT00085124 CALGB

Details

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

1 forms

StudyEvent: CALGB: OFF TREATMENT NOTICE
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Off Treatment Notice

CALGB Form

CALGB Study No

CALGB Patient ID

Amended data?

Yes

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No

Main Member Institution/Adjunct

Participating Group Patient No

REASON OFF TREATMENT

Adverse event (Adverse event)

Patient refused further protocol treatment, but consented to be followed. (Patient refused further protocol treatment, but consented to be followed.)

Patient refused further protocol treatment, withdrew consent to be followed. Patient is lost to follow-up. (Patient refused further protocol treatment, withdrew consent to be followed. Patient is lost to follow-up.)

Treatment never started (Treatment never started)

8 more items in the detailed view.

Patient developed other disease. Specify

Reason why treatment was not started

Specify type of non-protocol treatment:

Other, specify (off treatment reason)

LAST DATE OF PROTOCOL TREATMENT

M D Y

Comments

Completed By

Date Completed

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