Description:

E1905 Registration Worksheet (step 1) Azacitidine With or Without Entinostat in Treating Patients With Myelodysplastic Syndromes, Chronic Myelomonocytic Leukemia, or Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=74CCB3AB-1C3F-A75A-E040-BB89AD431F27

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=74CCB3AB-1C3F-A75A-E040-BB89AD431F27

Keywords:
Versions (4) ▾
  1. 12/18/14
  2. 12/22/14
  3. 1/9/15
  4. 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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E1905 Registration Worksheet (step 1)

No Instruction available.

  1. StudyEvent: E1905 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
Patient's simplified disease code
Has HIPAA authorization been obtained
Is the disease treatment-induced
Disease site/type
I agree biopsies may be done to obtain research specimens.
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
I agree to provide additional specimens for research
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
Someone from this institution may contact me in the future to ask me to take part in more research.
Race
Patient's Race
Patient Demographics / Pre-treatment Characteristics
Patient's Sex
Patient Ethnicity
Patient's simplified disease code
Method of payment (check one)
Country of residence
I Have Reviewed The Above Data And Agree The Date Are Accurate And Correct

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