INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center. Keep a copy for your files. NOTE: This form is required at the specified report periods regardless of whether new information is available
INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center. Keep a copy for your files. NOTE: This form is required at the specified report periods regardless of whether new information is available
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
CL Item
Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
CL Item
Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
CL Item
Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus) C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus) C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus) C1705108 (UMLS 2011AA)
NewCancerSiteText
Item
Site of new primary (s If new primary site is AML/MDS/ALL, submit NCI AML/MDS/ALL form If new primary site is other than AML/MDS/ALL, submit ECOG Second Primary Form)
Has the patient received any non-protocol cancer therapy prior to first progression (If yes, submit ECOG Non-Protocol Therapy Form - Note: Only the first occurrence of non-protocol therapy should be reported.)
Has the patient received any non-protocol cancer therapy prior to first progression (If yes, submit ECOG Non-Protocol Therapy Form - Note: Only the first occurrence of non-protocol therapy should be reported.)