Description:

Ovarian Function Suppression Form (Form 24-OFS) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70C65E9-F1BA-21F5-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70C65E9-F1BA-21F5-E034-0003BA12F5E7

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

September 17, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Ovarian Function Suppression Form (Form 24-OFS) - 2080631v3.0

OVARIAN FUNCTION SUPPRESSION FORM (Form 24-OFS) Instructions: This form is to be completed and submitted for patients randomized to Ovarian Function Suppression (OFS) and for patients who were not randomized to receive OFS but received it. Submit this form at each follow-up period (every three months in Year 1, every six months in Years 2-6) until the completion of OFS. (If patient receives surgical oophorectomy, submit this form only once. If patient receives bilateral ovarian radiation therapy, submit until ovarian function suppression is confirmed.) Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Ccrr Module For Ovarian Function Suppression Form-revised (form 24-ofs)
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period
If OFS will start later, reason
If stopped early or never started, reason (select one and sign & date at the bottom of this form - DataFax only page 1.)
Which method(s) of OFS did patient receive?
Gnrh Analogue
Agent Name
Route of Administration
Compliance Code
Reason not taken code
Is this the final treatment
Surgical Oophorectomy
Was the oophorectomy bilateral
This oophorectomy is (Report oophorectomy for reasons other than protocol-related ovarian function suppression on Forms 24-E and 24-GYN.)
Reason
Bilateral Ovarian Radiation Therapy
Confirmation Of Biochemical Evidence Of Cessation Of Ovarian Function After Ovarian Radiotherapy Is Completed.
This radiation therapy is
Reason

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