Description:

Z1041: Registration Worksheet NCT00513292 Combination Chemotherapy and Paclitaxel Plus Trastuzumab in Treating Women With Palpable Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211E7BC7-C479-7160-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=211E7BC7-C479-7160-E044-0003BA3F9857

Keywords:
Versions (6) ▾
  1. 8/26/12
  2. 8/11/14
  3. 1/9/15
  4. 6/27/15
  5. 7/25/15
  6. 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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Registration Worksheet Breast Cancer Z1041 NCT00513292

No Instruction available.

  1. StudyEvent: Z1041: Registration Worksheet
    1. No Instruction available.
Header Module
Visit
Has patient previously been registered to an ACOSOG study
Patient Information
Gender
Race (Mark all that apply)
Ethnicity (Mark only one)
Method of payment (Mark all that apply)
kg
cm
HIPAA Authorization form
Consent
Consent for correlative studies and specimen banking signed
Inclusion Criteria
Inclusion Criteria
Exclusion Criteria
Exclusion Criteria
Eligibility Assessment
Patient meets all eligibility criteria
In the opinion of the investigator, is the patient eligible?
Randomization (Please indicate "arm" assigned as a result of randomization:)
Baseline Performace Status (ECOG/modified Zubrod scale)
Method of Evaluation
Method of Evaluation
%
%
%
%
Pregnancy Test
Pregnancy test done
Reason pregnancy test not performed
Type of pregnancy test
Result
Primary Tumor Biopsy
Method of biopsy
Receptor Status, ER (mark one)
Marker Test Method (mark all that apply)
HER-2/neu status (mark one)
PgR Status (mark one)
Histologic Grade
Histologic Type
Clinical Stage
Clinical T Stage
Clinical N Stage
Is there a breast lesion >= 2 cm
Laboratory Values
g/dL
1000/uL
mg/dL
U/L
mg/dL
History
Hypertension
Smoking
Cardiac Disease History
Cardiovascular Disease
Diabetes
Hyperlipidemia
Has the patient had a prior history of breast cancer requiring radiation
Location of tumor (If yes,)
Footer
Did the Investigator sign the CRF indicating review of all data and certifying data are accurate and complete to the best of their knowledge

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