Unnamed2
Patient Initials
text
Participating Group
text
Medical Record Number
text
Study Number Participating Group
text
Institution Name
text
Trial subject ID Participating Group
text
Unnamed3
TreatmentReportingPeriodWeekNumber
float
TreatmentReportingPeriodWeekNumber
float
Hospitalization And Emergency Room Data
HospitalizationReportPeriodInd-2
boolean
TreatingHospitalName
text
HospitalIntensiveCareUnitAdmissionDayCount
float
HospitalAdmissionDate
date
InpatientDischargeDate
date
Outpatient Data And Home Visit Data
OutpatientTreatmentReportingPeriodInd-2
boolean
OtherTreatmentOutpatientVisitCount
float
Unnamed4
Protocol ID CALGB
text
Trial subject ID CALGB
text
Reporting Period Start Date
date
Unnamed5
Outpatient Data And Home Visit Data (continued From Previous Page)
TreatmentHomeVisitInd-3
boolean
TreatmentHomeVisitCount
float
Evaluation method
text
Evaluation method, specify
text
AssessmentPerformedCount
float
Operating Room Data
ProcedurePerformedType
text
PrimarySurgicalProcedurePerformedText
text
ProcedurePerformedCount
float
Non-protocol Chemotherapy Data
Non-protocolChemotherapyAdministeredInd-3
boolean
Agent
text
Agent
text
AgentCourseCount
float
Person Completing Form
text
Form Completion Date
date