Description:

NSABP B-45 Worksheet for Sunitinib/Placebo Treatment Form 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=61BA6471-86CD-B427-E040-BB89AD43714B

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=61BA6471-86CD-B427-E040-BB89AD43714B

Keywords:
Versions (2) ▾
  1. 8/27/12
  2. 1/9/15
Uploaded on:

January 9, 2015

DOI:
No DOI assigned. To request one please log in.
License:
Creative Commons BY-NC 3.0 Legacy
Model comments:

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for:

Item comments for:

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00914043 Treatment - NSABP B-45 Worksheet for Sunitinib/Placebo Treatment Form - 2830664v1.0

This paper worksheet may be completed to facilitate the entry of treatment information in NSABP Coordinator Online. Partially completed worksheets may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. While patient is taking Sunitinib/Placebo, treatment information will be collected for each of the following 7 Reporting Periods listed below. Form T does not apply to a patient who did not initiate Sunitinib/Placebo. If Sunitinib/Placebo is discontinued early, and the date Sunitinib/Placebo ended has been reported on a previous Form T, additional treatment forms will not be expected

Header
Reporting Period
Reporting Period (mark one)
Section 1. Sunitinib/placebo For All Patients
Were there any physician-directed treatment modifications during this interval
Dose modification (if yes mark all that apply)
Reason Treatment Ended (If hormonal therapy was discontinued during this interval Hormonal Therapy)
Estimate Of Patient Compliance
What percentage of the expected number of capsules did the patient take (Sunitinib/Placebo)
How was the number of capsules taken during this period determined (mark all that apply)
Section 2. Adjuvant Hormonal Therapy During Sunitinib/placebo Treatment
Has the patient received any hormone therapy during this reporting period? (Sunitinib/Placebo)
Was all hormonal therapy discontinued this report period (Sunitinib/Placebo)
Hormonal Agent When Hormonal Therapy was Permanently Discontinued
Was the discontinuation of hormonal therapy physician-directed
Reason Treatment Ended (If hormonal therapy was discontinued during this interval Hormonal Therapy)
Footer

Similar models