Description:

CALGB 90802 Follow-Up Form Everolimus With or Without Bevacizumab in Treating Patients With Advanced Kidney Cancer That Progressed After First-Line Therapy NCT01198158 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=87856A36-E884-CA3E-E040-BB89AD431C27

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=87856A36-E884-CA3E-E040-BB89AD431C27

Keywords:
Versions (3) ▾
  1. 9/19/12
  2. 1/8/15
  3. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Follow-Up Form Kidney Cancer (NCT01198158)

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

Header Module
Are data amended
Vital Status
Patient's Vital Status (Mark one with an X. If the patient is lost, follow instructions on form C-1742 and in the CALGB Policies and Procedures chapter 8 to have Data Operations change a patient's survival status to: "Confirmed lost to follow-up")
Primary Cause of Death (Mark one with an X.)
Karnofsky Performance Status Score (Mark one with an X.)
Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
Kg
Treatment Status (Mark one with an X)
Measurable Disease Response
Response Status at This Assessment (Mark one with an X.)
Sites of Progression (during this reporting period Mark all that apply with an X.)
Baseline Lab Values (hematologic)
1000/uL
g/dL
g/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Long-term Toxicity
Has the patient experienced post diagnosis of progression or new primary, any severe (Grade > 3), long-term toxicity that has not been previously reported
Non-protocol Therapy
Has the patient received any non-protocol cancer therapy during this reporting period?
Specify (If yes, Mark all that apply with an X below.)

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