E2906 Treatment Form - CONSOLIDATION - Arm C - Step 2 Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia 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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Leukemia NCT01041703 Treatment - E2906 Treatment Form - CONSOLIDATION - Arm C - Step 2 - 2949165v1.0

INSTRUCTIONS: Complete this form at the end of each cycle of Arm A Consolidation protocol treatment. Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule

On Treatment
Reporting Period
Section Ii - Reporting Period
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Patient Characteristics
Age group
Therapy Administered
Was the agent administered during this reporting period? (Cytarabinecycle)
Dose modification
Dose Modification Reason
On which dose schedule was agent administered (Cytarabine)
Other Therapy Administered
Did patient receive Dexamethasone this reporting period (as an anti-emetic cycle)
Non-protocol Therapy
Was any non-protocol therapy given during protocol treatment? (not previously reported )

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