Description:

E5204 Registration Worksheet (step 1) Combination Chemotherapy With or Without Bevacizumab in Treating Patients Who Have Had Surgery for Stage II or Stage III Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510DE449-8B3B-632C-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=510DE449-8B3B-632C-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/27/12
  2. 1/9/15
  3. 9/17/21
Uploaded on:

September 17, 2021

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00303628 Eligibility - E5204 Registration Worksheet (step 1) - 2762495v1.0

No Instruction available.

  1. StudyEvent: E5204 Registration Worksheet (step 1)
    1. No Instruction available.
Eligibility
Has the eligibility checklist been completed
In the opinion of the investigator, is the patient eligible?
Has written informed consent been obtained
Has HIPAA authorization been obtained
ECOG Performance Status
What is the patient's clinical staging risk status
What is the patient's clinical staging risk status
Did the patient receive prior pre-operative oxaliplatin
Did the patient participate on NSABP R-04 trial
Total pre-operative radiation dose
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
I agree to participate in the protein and DNA studies that are being done as part of this clinical trial.
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
Someone from this institution may contact me in the future to ask me to take part in more research.
Patient Demographics / Pre-treatment Characteristics
Patient's Sex
Patient Race (check all that applyU.S. and Canada only)
Patient Ethnicity
Method of payment (check one)

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