CALGB: 10201On-Study Form Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder:


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  1. 9/19/12
  2. 1/9/15
  3. 9/27/21
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September 27, 2021

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Leukemia NCT00085124 On-Study - CALGB: 10201On-Study Form - 2057573v3.0

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

Calgb Form
Patient Description
Clinical Onset of AML
Extramedullary Disease Involvement (mark all that apply)
Are Auer Rods present?
Organ Involvement
Palpable Splenomegaly
Splenomegaly by scan or x-ray
Palpable Heptomegaly
Hepatomegaly by scan or x-ray
Palpable Lymphadenopathy
Lymphadenopathy by scan or x-ray
Current Symptoms
Current Infection (mark one with an X)
Bleeding/Hemorrage (mark one with an X)
Lab Data At Study Entry
Ccrr Module For Calgb: 10201on-study Form

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