Description:

CALGB 80702 Follow-Up Form Oxaliplatin, Leucovorin Calcium, and Fluorouracil With or Without Celecoxib in Treating Patients With Stage III Colon Cancer Previously Treated With Surgery NCT01150045 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7ADB9225-BF4C-FA4C-E040-BB89AD4369EB

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7ADB9225-BF4C-FA4C-E040-BB89AD4369EB

Keywords:
Versions (2) ▾
  1. 8/27/12
  2. 1/8/15
Uploaded on:

January 8, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Follow-Up Form Colorectal Cancer (NCT01150045)

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. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, 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 form

Header Module
Are data amended
Vital Status
Treatment type (Mark one with an X.)
Vital Status (Mark one with an X.)
Primary Cause of Death (Mark one with an X.)
Disease Status
Has the patient had a documented clinical assessment for this cancer?
Current disease status (Mark one with an X.)
Sites Of Relapse
Site of relapse/progression (Mark all that apply with an X.)
Colonoscopy Information
Has the patient had a colonoscopy assessment for this cancer since submission of the previous follow-up form?
Were any samples sent to pathology
Colonoscopy findings (Mark all that apply with an X.)
Neuropathy
CTC Adverse Event Peripheral Sensory Neuropathy Grade
Non-protocol Treatment
Has the patient received any non-protocol cancer therapy during this reporting period?
New Primary Data
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Site of new primary (Mark one with an X.)

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