Southwest Oncology Group S0931 Treatment Form (Form #44488) Everolimus in Treating Patients With Kidney Cancer Who Have Undergone Surgery Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
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January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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Kidney Cancer NCT01120249 Treatment - Southwest Oncology Group S0931 Treatment Form (Form #44488) - 2992372v1.0

Instructions: Please complete this form after every cycle (1 cycle = 42 days, regardless of dose delays). All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form

Vital Status
Has the patient progressed per the definition in Section 10.0 of the protocol?
Treatment For This Cycle
Did the patient have radiographic evidence of pneumonitis?
Were there any dose modifications or additions/omissions to protocol treatment?
mg/24 hours
mg/24 hours
Agent dose modification
Dose Modification Reason
Modification due to Adverse Event

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