Description:

Tamoxifen/Exemestane Form (Form 24-TE) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70B84C2-ED22-2268-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70B84C2-ED22-2268-E034-0003BA12F5E7

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

January 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Tamoxifen/Exemestane Form (Form 24-TE) - 2080772v3.0

TAMOXIFEN/EXEMESTANE FORM (Form 24-TE) Instructions: This form is to be completed and submitted for all patients at each follow-up period (every 3 months in Year 1, and every 6 months in Years 2-6) until the completion of Tamoxifen/Exemestane. Report Tamoxifen/Exemestane given as treatment for recurrence/second primary on the Follow-Up Form (24-E). If patient is receiving another aromatase inhibitor,report on the Concomitant Medications Form (24-CCM). Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Ccrr Module For Tamoxifen/exemestane Form - Revised (form 24-te)
Is this the first follow-up period during which the patient has taken Tamoxifen or Exemestane
Tamoxifen
Did patient receive Tamoxifen during this follow-up period (select all that apply)
Yes, took Tamoxifen but randomized to Exemestane, check reason (select one) (select one)
Compliance Code
Reason not taken code
Reason non-protocol dose used
Reason for Interruption Code
If Tamoxifen stopped early or never started, reason (select one)
If Tamoxifen will start later, reason
Exemestane
Did patient receive Exemestane during this follow-up period (select all that apply)
Yes, took Exemestane but randomized to Tamoxifen, check reason (select one)
Compliance Code
Reason not taken code
Reason non-protocol dose used
Reason for Interruption Code
If Exemestane stopped early or never started, reason (select one)
If Exemestane will start later, reason

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