Description:

E2906 Allogeneic Transplant Form - Arm G Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=758373C9-BE14-F79E-E040-BB89AD433D62

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=758373C9-BE14-F79E-E040-BB89AD433D62
Keywords:
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT01041703 Treatment - E2906 Allogeneic Transplant Form - Arm G - 2951703v1.0

INSTRUCTIONS: Complete this form after the allogeneic transplant (30 days post transplant or at the end of hospitalization). Submit original to the ECOG Coordinating Center; keep a copy for your files

Header
On Treatment
On Treatment Reporting Period
Unnamed2
Vital Status
Patient's Vital Status
Kg
Primary Cause of Death (if applicable)
Section Ii - Reporting Period
Therapy Administered
Dose modification
Dose Modification Reason
Donor Information
Donor's Relationship to recipient
Donor Gender
CMV status (Patient)
EBV status
Are patient and donor matched at HLA-A
Are patient and donor matched at HLA-B
Are patient and donor matched at HLA-C
Are patient and donor matched at HLA-DR
Are patient and donor matched at HLA-DQ
Are patient and donor matched at HLA-DP
Allogeneic Transplant
Did the patient receive protocol transplant?
Source of Stem Cells (If yes)
CMV status (Patient)
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