Description:

NSABP B-45 Worksheet for Reporting Initiation of Sunitinib/Placebo Studying Biological Markers of Fatigue in Women With Residual Invasive Breast Cancer Enrolled on Clinical Trial NSABP-B-45 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=61A68212-D8B0-0740-E040-BB89AD431DF9

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=61A68212-D8B0-0740-E040-BB89AD431DF9

Keywords:

Breast Neoplasms

8/27/12 8/27/12 -
1/9/15 1/9/15 - Martin Dugas

Uploaded on:

January 9, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00914043 Treatment - NSABP B-45 Worksheet for Reporting Initiation of Sunitinib/Placebo - 2830516v1.0

This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For all patients, information on initiation of Sunitinib/Placebo must be reported within 4 weeks following randomization

StudyEvent: NSABP B-45 Worksheet for Reporting Initiation of Sunitinib/Placebo
1. This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. For all patients, information on initiation of Sunitinib/Placebo must be reported within 4 weeks following randomization

Header Module

Patient Initials (Last First Middle)

NSABP Patient ID

All Patients

Did the patient begin Sunitinib/Placebo

Yes

No

Agent Start Date (Sunitinib/Placebo Month Day Year)

Reason Treatment did not begin (Sunitinib/Placebo)

Patient Withdrawal Or Refusal (Patient withdrawal or refusal)

New Lesion (including Second Primary Cancer) Or Other Sign Of Progression (New lesion (including second primary cancer) or other sign of progression)

Death (Death)

Alternative Therapy (Alternative therapy)

Other (Other)

Other, specify

Footer Module

Comments (optional)

Person Completing Form

Date Form Completed (MM DD YYYY)

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