Description:

CALGB 90802 On-Study Form Everolimus With or Without Bevacizumab in Treating Patients With Advanced Kidney Cancer That Progressed After First-Line Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=88715713-3A23-2D6C-E040-BB89AD433D3B

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=88715713-3A23-2D6C-E040-BB89AD433D3B

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Versions (2) ▾
  1. 9/19/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Kidney Cancer NCT01198158 On-Study - CALGB 90802 On-Study Form - 3107346v1.0

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy complete the form electronically. After entering all data, click the "Print and/or Submit to CALGB" button located at the bottom of the last page of the form. Retain a copy of the form for your records. Submit supporting documentation by fax (919-416-4990) or mail. If data are amended, circle amended items, check the "Yes" box, and submit by fax or mail

Ccrr Module For Calgb 90202: Skeletal Survey Form
Are data amended
Patient Description
Karnofsky Performance Status Score (Mark one with an X.)
History of Prior Malignancy
Histologic grade (Mark one with an X.)
Disease Stage (Mark one with an X.)
Sites Of Disease
Sites of Disease (Mark all that apply with an X.)
Dominant Histology (Mark all that apply with an X.)
Baseline Lab Values (hematologic)
1000/uL
g/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
Urinalysis
Urinalysis result (OR)
g/24 hours
If the patient is registered to CALGB 580902 were MRIs submitted to the Central Imaging Core laboratory for
Prior Treatment
Prior Treatment
Specify (If yes Mark all that apply with an X. Add date started and ended)
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