Description:

GOG-0262: Common Toxicity Reporting Form (Form T) Paclitaxel and Carboplatin With or Without Bevacizumab in Treating Patients With Stage II, Stage III, or Stage IV Ovarian Epithelial Cancer, Primary Peritoneal Cancer, or Fallopian Tube Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E5FD374-D92A-C069-E040-BB89AD4333F9

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E5FD374-D92A-C069-E040-BB89AD4333F9
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Versions (3)
  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
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Fallopian Tube Cancer NCT01167712 Toxicity - GOG-0262: Common Toxicity Reporting Form (Form T) - 2918112v1.0

English
Details

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1 forms  
  1. StudyEvent: GOG-0262: 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
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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