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CALGB 80702 Registration Worksheet Form Oxaliplatin, Leucovorin Calcium, and Fluorouracil With or Without Celecoxib in Treating Patients With Stage III Colon Cancer Previously Treated With Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7AD9533B-3CE6-57A8-E040-BB89AD434546

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7AD9533B-3CE6-57A8-E040-BB89AD434546

Keywords:

Colorectal Neoplasms

Clinical Trial

Registration

Versions (4)

8/27/12 8/27/12 -
1/9/15 1/9/15 - Martin Dugas
1/9/15 1/9/15 - Martin Dugas
9/17/21 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 NCT01150045 Registration - CALGB 80702 Registration Worksheet Form - 2969752v1.0

English 1

English

Details

A Phase III Trial of 6 Versus 12 Treatments of Adjuvant FOLFOX Plus Celecoxib or Placebo for Patients with Resected Stage III Colon Cancer

1 forms

StudyEvent: CALGB 80702 Registration Worksheet Form
1. A Phase III Trial of 6 Versus 12 Treatments of Adjuvant FOLFOX Plus Celecoxib or Placebo for Patients with Resected Stage III Colon Cancer

Header Module

Lead Institution

Institution/Affiliate

Participating Group Name

CALGB Patient ID

Physician

Principal Investigator No.

Protocol Administration

IRB Approval Date (MM DD YYYY)

Date Informed Consent Signed (MM DD YYYY)

Projected Start Date of Treatment (MM DD YYYY)

HIPAA Authorization Date (MM DD YYYY)

Institution contact

Phone

Fax

Patient Demographics/pre-treatment Characteristics

Patient Initials (Last, First Middle)

Date of Birth (MM DD YYYY)

Patient Social Security Number

Patient Hospital No.

Gender

Male (MALE)

Female (FEMALE)

Race (Mark all that apply)

A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment. (American Indian or Alaska Native)

A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)

A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)

A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands. (Native Hawaiian or other Pacific Islander)

Could Not Be Determined Or Unsure (Unknown)

A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)

Ethnicity (Mark one)

A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)

A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)

Could Not Be Determined Or Unsure (Unknown)

Patient Demographics/pre-treatment Characteristics2

Performance Status (ECOG/Zubrod scale)

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)

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)

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)

Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)

Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)

Dead (5)

Height (cm)

Weight (kg)

Body Surface Area (m^2)

Method of Payment (USA only Mark one)

Medicaid (Medicaid)

Medicaid And Medicare (Medicaid and Medicare)

Medicare (Medicare)

Medicare And Private Insurance (Medicare and Private Insurance)

7 more items in the detailed view.

Patient Demographics/pre-treatment Characteristics3

Disease

Patient Zip Code

Country of Residence (If not USA)

Certification Of Eligibility And Protocol Design

In the opinion of the investigator, is the patient eligible for 80702

Yes

In the opinion of the investigator, is the patient eligible for 150911

Yes

In the opinion of the investigator, is the patient eligible for 60905

Yes

Protocol Design

Stratification Factors

Assigned Treatment Arm

Initial Patient Consent For Specimen Use

Did the patient agree to participate in the Diet and Lifestyle study and complete the diet and lifestyle questionnaire

Yes

Patient's Initial Consent given for specimen use for research on the patient's cancer

Yes

Patient's initial consent given for blood specimen use for genetic research on patient's cancer?

Yes

Patient's Initial Consent given for specimen kept for future use in research to learn about, prevent, or treat cancer

Yes

Patient's Initial Consent given for specimen use for research unrelated to the patient's cancer?

Yes

Patient's initial consent given for further contact regarding specimen?

Yes

Notes

CRA Name

CRA e-mail

CRA mailing address

CRA Phone

Registration Information

Registration Date (MM DD YYYY)

Participating Group Patient ID