Description:

GOG-0258 Common Toxicity Reporting Form (T) Carboplatin and Paclitaxel With or Without Cisplatin and Radiation Therapy in Treating Patients With Stage I, Stage II, Stage III, or Stage IVA Endometrial Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=644E86D7-E2E5-D7C8-E040-BB89AD4321CC

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=644E86D7-E2E5-D7C8-E040-BB89AD4321CC
Keywords:
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

DOI:
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Creative Commons BY-NC 3.0 Legacy
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Endometrial Cancer NCT00942357 Toxicity - GOG-0258 Common Toxicity Reporting Form (T) - 2845153v1.0

No Instruction available.

  1. StudyEvent: GOG-0258 Common Toxicity Reporting 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 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
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