Description:

GOG-0263: Common Toxicity Reporting Form (Form T) Radiation Therapy With or Without Chemotherapy in Patients With Stage I or Stage II Cervical Cancer Who Previously Underwent Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7170934C-5E7F-20E2-E040-BB89AD434964

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7170934C-5E7F-20E2-E040-BB89AD434964

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Versions (3) ▾
  1. 8/27/12
  2. 1/9/15
  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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Cervical Cancer NCT01101451 Toxicity - GOG-0263: Common Toxicity Reporting Form (Form T) - 2933725v1.0

No Instruction available.

  1. StudyEvent: GOG-0263: Common Toxicity Reporting Form (Form T)
    1. No Instruction available.
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?
Adverse Events - Section 2
Peripheral WBC count done
1000/uL
CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
Peripheral ANC/Granulocytes count done (ANC/)
1000/uL
SAE report submitted
SAE report submitted
SAE report submitted
SAE report submitted
Peripheral Platelet count done
1000/uL
Hemoglobin done
g/dL
Adverse Events - Section 3
CTC Adverse Event Attribution Code (Attribution Codes for Relationship of Event to Treatment: 1=Unrelated, 2=Unlikely, 3=Possibly, 4=Probably, 5=Definitely)
Present Status
The CTCAE data entered above is
SAE report submitted
Comments

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