Module 1
Protocol ID RTOG
text
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Institution Name
Institution Number
Patient Initials
Trial subject ID RTOG
Data amended
boolean
Assessment
Patient Height
float
Patient Weight
Body Surface Area
Unnamed 3
Agent
Medication End Date
date
Number of Doses, Total
Medication Dose
Medication Start Date
Cumulative Dose Agent
Dose Modification
Off Treatment Reason
Alternative therapy, specify
Off Treatment Reason, specify
TherapyModificationText
Protocol Specific Adverse Event Evaluation
Adverse Event
MedDRACode
AdverseEventCommonTerminologyforAdverseEventsVersion4TermName
CommonToxicityCriteriaAdverseEventGrade
CTCAdverseEventReportBeginDate
CTCAdverseEventAttributionScale
SeriousAdverseEventReportInd-3
Unnamed3
LaboratoryProcedureResultUnitofMeasureType
LaboratoryProcedureHemoglobinResultSpecifiedValue
LaboratoryProcedureHematocritOutcomePercentageValue
Leukocytes (WBC)
Platelets
Neutrophil percentage
Neutrophil count
LaboratoryProcedureSodiumElectrolytesOutcomeSpecifiedValue
LaboratoryProcedurePotassiumElectrolytesOutcomeSpecifiedValue
LaboratoryProcedureChlorideIonElectrolytesOutcomeSpecifiedValue
Blood Urea Nitrogen
Creatinine, Serum
Creatinine Clearance
LaboratoryProcedureTotalBilirubinResultSpecifiedValue
Alkaline Phosphatase
LDH
SGOT (AST)
SGPT (ALT)
Protein, Serum Total
LaboratoryProcedureTotalUrineProteinOutcomeUnspecifiedValue
Albumin
LaboratoryProcedureUricAcidResultSpecifiedValue
LaboratoryProcedureCalciumElectrolytesOutcomeValue
LaboratoryProcedureGlucoseElectrolytesOutcomeUnspecifiedValue
LaboratoryProcedureMagnesiumResultSpecifiedValue
LaboratoryProcedurePerformedSpecify
LaboratoryProcedurePerformedValue
Unnamed Module 4
Research Comments
Investigator Signature
Investigator Signature Date