Description:

CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CE624-6F5F-37E3-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CE624-6F5F-37E3-E034-080020C9C0E0

Keywords:

Breast Neoplasms

4/19/12 4/19/12 -
12/16/14 12/16/14 - Martin Dugas

Uploaded on:

December 16, 2014

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00024102 Transmittal - CALGB 49907 CAPECITABINE DRUG SUPPLY RECORD FORM 2044684_v3_0

INSTRUCTIONS: Complete and submit this 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. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

StudyEvent: CALGB: 49907 CAPECITABINE DRUG SUPPLY RECORD FORM
1. INSTRUCTIONS: Complete and submit this 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. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

General information

CALGB Form

CALGB Study No

CALGB Patient ID

Last date of reporting cycle (M)

Amended data?

Yes (Yes)

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

Medication

Daily capecitabine dose (mg)

Number of 500 mg tablets prescribed to be taken each day

Number of 500 mg tablets issued

Date and time the electronic device was placed on the vial (Use a military-24 hour clock)

Name of the person who filled the vial (Use a military-24 hour clock)

Date and Time pill count was done

How many 500 mg tablets returned (Exact pill count)

Date and time the electronic device was removed from the vial (Use a military-24 hour clock)

Name of the person who performed the return pill count

Completed By (Print or Type Name)

Date Completed (M)

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