E3F05 Chemotherapy Form - Arm B Only Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma NCT00978458 Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 1/1/15 1/1/15 - Martin Dugas
Uploaded on:

January 1, 2015

To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

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
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 )

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial