Description:

North Central Cancer Treatment Group Arms A and D Only Recurrent Research Tissue Submission Form NCT00079274 Comparison of Combination Chemotherapy Regimens With or Without Cetuximab in Treating Patients Who Have Undergone Surgery For Stage III Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8BC1F4CF-E66A-E266-E040-BB89AD436B4E

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8BC1F4CF-E66A-E266-E040-BB89AD436B4E

Keywords:

Colorectal Neoplasms

Versions (4) ▾

8/27/12
1/9/15
6/8/15
9/20/21

Uploaded on:

September 20, 2021

DOI:

No DOI assigned. To request one please log in.

License:

Creative Commons BY-NC 3.0 Legacy

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North Central Cancer Treatment Group Arms A & D Only Recurrent Research Tissue Submission Form NCT00079274

Details

INSTRUCTIONS: Required for all Arm A and D patients having had a surgical resection for recurrent disease per Addendum 12. Submit this form <= 30 days following surgical resection following disease progression or <= 30 days following activation of Addendum 12 (dependent on IRB approval) if patient has already had disease recurrence and surgical resection to:

StudyEvent: North Central Cancer Treatment Group Arms A & D Only Recurrent Research Tissue Submission Form
1. INSTRUCTIONS: Required for all Arm A and D patients having had a surgical resection for recurrent disease per Addendum 12. Submit this form <= 30 days following surgical resection following disease progression or <= 30 days following activation of Addendum 12 (dependent on IRB approval) if patient has already had disease recurrence and surgical resection to:

Header module

Coordinating Group Protocol Number

Coordinating Group Code

Protocol Title

Patient Study ID

Patient Medical Record Number

Patient Initials (L, FM)

Participating Group Code (Cooperative Group where credit will be applied)

Institution Name

Visit

Instructions

Patient's re-consent given for recurrent tissue specimen use for research on the patient's cancer? (per Addendum 12)

Yes

No

Was sample obtained (check one)

Yes

No

Date of collection (If yes, mm/dd/yyyy)

Date Specimen Shipped (mm/dd/yyyy)

Reason (If no check one)

Facility Will Not Release Block (Facility will not release block)

Block Depleted/insufficient Tissue (Block depleted/insufficient tissue)

Other (Other)

Number of slides sent

Institution Name

Number of blocks sent

Accession Number (s on the blocks sent)

Accession Number (s on the blocks sent)

Contact Person at Institution (Institutional Contact Information: CRA/Nurse)

Street Address

Phone Number

Fax Number

Email address

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