E5204 Adverse Event Form (CTCAE v3.0) Combination Chemotherapy With or Without Bevacizumab in Treating Patients Who Have Had Surgery for Stage II or Stage III Rectal Cancer NCT00303628 Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
  5. 3/31/15 3/31/15 - Martin Dugas
  6. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer Toxicity NCT00303628 E5204

INSTRUCTIONS: Complete this form as indicated below and at the end of all protocol therapy. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

Adverse event
On Treatment Report Period (Arms A and B)
Off Treatment Report Period (since initial registration)
Were adverse events assessed during this report period (cycle)
Adverse event blood, bone marrow lab
CTC Adverse Event Term (Type)
CTC Adverse Event Attribution Scale
Adverse event infections
CTC Adverse Event Short Name (use CTCAE v3 terminology)
Other Adverse Events

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