Description:

SWOG S1201 Registration Worksheet Form Combination Chemotherapy in Treating Patients With Advanced or Metastatic Esophageal Cancer, Gastric Cancer, or Gastroesophageal Junction Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5907598-58E9-643E-E040-BB89AD4312F7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5907598-58E9-643E-E040-BB89AD4312F7

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

August 26, 2012

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License:
Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01498289 Registration - SWOG S1201 Registration Worksheet Form - 3341218v1.0

INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data.

Unnamed1
Swog Patient Id
SWOG Patient ID Status
Demography
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Unnamed5
Stratification Question
Primary Disease Site
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My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
Someone may contact me in the future to ask me to allow other uses of my specimens.
I agree to allow my study doctor, or someone approved by my study doctor, to contact me regarding future research involving my participation in this study
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Has the SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?