Description:

RTOG-1010 A0 Registration Worksheet Form Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=903C5206-1852-6ECF-E040-BB89AD435F63

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=903C5206-1852-6ECF-E040-BB89AD435F63

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Versions (2) ▾
  1. 12/18/14
  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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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG-1010 A0 Registration Worksheet Form - 3137697v1.0

No Instruction available.

  1. StudyEvent: RTOG-1010 A0 Registration Worksheet Form
    1. No Instruction available.
Module 1
Has the Step 1 eligibility checklist been completed
In the opinion of the investigator, is the patient eligible?
Race
Any care at VA or military hospital
Have you obtained the patient's consent for his or her tissue to be kept for use in research to learn about, prevent, treat or cure cancer
Have you obtained the patient's consent for his or her blood to be kept for use in research to learn about, prevent, treat, or cure cancer?
Have you obtained the patient's consent for his or her urine to be kept for use in research to learn about, prevent, treat, or cure cancer
Have you obtained the patient's consent for his or her tissue to be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease and heart disease)?
Have you obtained the patient's consent for his or her blood to be kept for use research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)?
Have you obtained the patient's consent for his or her urine to be kept for use in research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
Have you obtained the patient's consent to allow someone from this institution to contact him or her in the future to take part in more research