Description:

NCT00980954 RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Adjuvant System Treatment Summary Form (SF) Chemotherapy and Pelvic Radiation Therapy With or Without Additional Chemotherapy in Treating Patients With High-Risk Early-Stage Cervical Cancer After Radical Hysterectomy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5CFDEE98-0544-2FA7-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5CFDEE98-0544-2FA7-E044-0003BA3F9857

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Versions (6) ▾
  1. 8/27/12
  2. 1/9/15
  3. 1/9/15
  4. 1/9/15
  5. 7/8/15
  6. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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NCT00980954 RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Adjuvant System Treatment Summary Form (SF)

INSTRUCTIONS: Submit this form at the completion of each cycle of salvage treatment. Dates are to be recorded as mm-dd-yyyy unless otherwise specified

  1. StudyEvent: RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Adjuvant System Treatment Summary Form (SF)
    1. INSTRUCTIONS: Submit this form at the completion of each cycle of salvage treatment. Dates are to be recorded as mm-dd-yyyy unless otherwise specified
RTOG clinical trial administrative data
Amended Data (INSTRUCTIONS: Complete form on web to unblind the protocol treatment arm)
Assessment
cm
Kg
m2
Was dose re-calculated due to elevated serum creatinine
Dose modification
Treatment Summary
Dose Modification (Change)
Reason Treatment Ended
Protocol Specific Adverse Event Evaluation
Any adverse events
CTC Adverse Event Term
Attribution
SAE report submitted
Lab results
Units
g/dL
%
1000/uL
%
mmol/L
mmol/L
mEq/L
mg/dL
1000/uL
U/L
U/L
mg/dL
mg/dL
mmol/L
Comments

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