Non-Hodgkin's Lymphoma - Follow Up Form Source Form: NCI FormBuilder:


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  3. 1/9/15
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January 9, 2015

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Follow-Up - Non-Hodgkins Lymphoma - Follow Up Form - 2270441v3.0

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  1. StudyEvent: Non-Hodgkins Lymphoma - Follow Up Form
    1. No Instruction available.
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Lymphoma: Vital Status
Patient Vital Status
Primary Cause of Death
Was the cause cardiac, infection, or other (If due to protocol treatment,)
Medical Symptoms Present at Time of Death (possible contributing causes)
is patient still being followed (If patient is alive,)
Is the patient off study
Off Study Reason (If yes,)
Lymphoma: Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
Lymphoma: Notice Of Progression Of Non-hodgkin's Lymphoma
Has the patient developed a first progression (or relapse) that has not been previously reported?
Sites of Progression (mark all that apply)
Lymphoma: Post-protocol Treatment
Is the patient going to start any new treatment after protocol treatment is completed
Type of Next Treatment (If yes,)
Lymphoma: Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Lymphoma: Long-term Toxicity
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported

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