E3F05 Neurologic Function Status and KPS Form Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder:

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  2. 12/3/14 12/3/14 - Martin Dugas
  3. 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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Brain and Central Nervous System Tumors NCT00978458 On-Study - E3F05 Neurologic Function Status and KPS Form - 2901661v1.0

INSTRUCTIONS: Complete this form according to the on-treatment and follow up schedules. Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule

Header Module
On Treatment
On Treatment Report Period (Choose one)
Off Treatment
Off Treatment Report Period (Choose one)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Patient Characteristics
Neurologic Function Status
Karnofsky Performance Status (%)
Footer Module

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