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CALGB 90601 Registration Worksheet Gemcitabine Hydrochloride and Cisplatin With or Without Bevacizumab in Treating Patients With Advanced Urinary Tract Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=653F1390-699C-B455-E040-BB89AD4361B9

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=653F1390-699C-B455-E040-BB89AD4361B9

Keywords:

Clinical Trial

Registration

Urinary Bladder Neoplasms

Versions (4)

12/18/14 12/18/14 - Martin Dugas
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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Bladder Cancer NCT00942331 Registration - CALGB 90601 Registration Worksheet - 2848728v1.0

English 1

English

Details

No Instruction available.

1 forms

StudyEvent: CALGB 90601 Registration Worksheet
1. No Instruction available.

Header Module

Lead Institution

Institution/Affiliate

Physician of Record

Participating Group Name

CALGB Patient ID (Assigned)

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

Stage

Pathologic type

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?

Yes

Protocol Design

Stratification Factors

Presence of visceral metastasis

Yes

Assigned Treatment Arm

Kit number

Initial Patient Consent For Specimen Use

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

Yes

Patient's initial consent given for specimen use for genetic research relating to the study treatment

Yes

My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.

Yes

My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).

Yes

My doctor or someone from CALGB may contact me in the future to ask me to take part in more research

Yes

Prior Cancer Therapies

Other Prior Therapy

Yes

Prior therapy type

Agents Administered To Control The Replication And/or Spread Of Viruses (Anti-retroviral therapy)

Treatment With An Agent That Prevents Or Impairs The Translation Of The Genetic Message For Production Of A Specific Protein (Antisense)

High Dose Chemotherapy Combined With Transplantation Of Bone Marrow Cells (Bone marrow transplant)

Non-systemic Chemotherapy Treatment Or Chemotherapy Not Described By Chemotherapy Single Agent Systemic Or Multi-agent Systemic (Chemotherapy (NOS))

11 more items in the detailed view.

Number of prior chemotherapy regimens

Registration Information

CALGB Patient ID (Assigned)

Registration Date (MM DD YYYY)

Participating Group Patient ID (Assigned)

Registrar's Signature

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