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NSABP PROTOCOL R-04: REGISTRATION FORM NCT00058474 Radiation Therapy and Either Capecitabine or Fluorouracil With or Without Oxaliplatin Before Surgery in Treating Patients With Resectable Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B7825AE7-F18A-259D-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B7825AE7-F18A-259D-E034-0003BA12F5E7

Keywords:

Colorectal Neoplasms

Clinical Trial

Registration

Versions (4)

12/18/14 12/18/14 - Martin Dugas
1/9/15 1/9/15 - Martin Dugas
6/29/15 6/29/15 -
9/20/21 9/20/21 -

Uploaded on:

September 20, 2021

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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NSABP PROTOCOL R-04: REGISTRATION FORM NCT00058474

English 1

English

Details

#Not required for patients =70 years if age, For patients < 70 years of age with a serum creatinine > ULN either a measured or a calculated creatinine clearance is required.

1 forms

StudyEvent: NSABP PROTOCOL R-04: REGISTRATION FORM
1. #Not required for patients =70 years if age, For patients < 70 years of age with a serum creatinine > ULN either a measured or a calculated creatinine clearance is required.

Ccrr Module For Nsabp Protocol R-04: Registration Form

NSABP Patient ID

Patient Medical Record Number

Institution Name

Institution Number

Affiliate Name

Physician of Record (physician to whom subsequent bottles will be sent must have a valid FDA Number)

Date Informed Consent Signed (Month Day Year)

Person Completing Form, Last Name

Person Completing Form, First Name

Person Completing Form, Phone

Person Completing Form, Fax

Last

First

Middle

Patient Birth Date (Month Day Year)

Patient Social Security Number (USA only)

Race Categories (more than one may be marked)

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

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)

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

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 Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (American Indian or Alaska Native)

Patient Is Unsure Of Their Race (Unknown)

Method of Payment (mark primary method only)

Private Insurance (Private Insurance)

Medicare (Medicare)

Medicare And Private Insurance (Medicare & Private)

Medicaid (Medicaid)

8 more items in the detailed view.

Ethnicity

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. (Non-Hispanic)

Patient Is Unsure Of Their Ethnicity (Unknown)

Other

Patient's Zip Code (USA)

Performance Status

Fully active, able to carry on all pre-disease performance without restriction (Fully active, able to carry on all pre-disease performance without restriction)

Restricted in physically strenous activity but ambulatory (Restricted in physically strenous activity but ambulatory)

Ambulatory and capable of all selfcare but unable to carry out any work activities (Ambulatory and capable of all selfcare but unable to carry out any work activities)

Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours)

Completely disabled (Completely disabled)

Patient Height

Patient Weight

Patient Gender

Female Gender (FEMALE)

Male Gender (MALE)

In the opinion of the investigator, is the patient eligible?

Yes

Certificiation Of Eligibility

Date

Method of Evaluation (or)