Description:

E3F05 Chemotherapy Form - Arm B Only Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma NCT00978458 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6D055B43-63F1-A6F7-E040-BB89AD436A92

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6D055B43-63F1-A6F7-E040-BB89AD436A92

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

January 1, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00978458 Treatment - E3F05 Chemotherapy Form - Arm B Only - 2904374v1.0

INSTRUCTIONS: Complete this form at the end of radiation/chemoradiation therapy, at the end of cycles 1, 2, 3, and at the end of cycles 6 (covering cycles 4-6), 9 (covering cycles 7-9) and 12 (covering cycles10-12). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule

Header Module
On Treatment Report Period (Choose one)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Patient Characteristics
Kg
m2
Therapy Administered
Was the agent administered during this reporting period? (Temozolomide)
Dose level administered this report period
Did the patient complete Patient Pill Diary (if yes, please submit this form to ECOG with E3F05 Source Document Tracking Coversheet)
Why were doses missed (Check all that apply)
Non-protocol Therapy
Was any non-protocol therapy given during protocol treatment? (not previously reported )

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