Description:

GOG Common Toxicity Reporting Form Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B3D1-8528-2473-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA3B3D1-8528-2473-E034-0003BA12F5E7

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  1. 8/27/12
  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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Cervical Cancer NCT00064077 Toxicity - GOG Common Toxicity Reporting Form - 2059265v3.0

FORM T

  1. StudyEvent: GOG Common Toxicity Reporting Form
    1. FORM T
Header Module
Adverse Events - Section 1
Has the patient received any transfusions during this course of therapy?
Was patient hospitalized as a result of reported adverse events?
Were cytokines administered this course?
Has an Adverse Drug Reaction Report been filed?
Adverse Events - Section 2
Peripheral WBC count, Done
Peripheral Granulocytes count, Done
Peripheral Platelet count, Done
Hemoglobin, Done
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Adverse Events - Section 3
CTC Adverse Event Attribution (* Attribution Codes for Relationship of Event to Treatment: 1 = Unrelated, 2 = Unlikely, 3 = Possibly, 4 = Probably, 5 = Definitely)
Comments
Footer Module
Ccrr Module For Gog Common Toxicity Reporting Form

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