NSABP Protocol B-43 - Protocol Entry Form Worksheet Radiation Therapy With or Without Trastuzumab in Treating Women With Ductal Carcinoma In Situ Who Have Undergone Lumpectomy Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00769379 Registration - NSABP Protocol B-43 - Protocol Entry Form Worksheet - 2679593v1.0

Submit every 6 months from date of randomization for the first 5 years; yearly thereafter, and when a protocol event occurs. Fax Form F to 412-622-2111

Person Completing Form, Last Name
Method of Payment (mark primary method only)
Country of Residence (if not USA)
Receptor Status
Receptor Status, ER
Receptor Status, PgR
Nuclear Grade
Plan for hormonal therapy
Patient Characteristics
Did patient consent to future contact about more research?
Has the patient authorized the release of Protected Health Information to the NSABP?
In the opinion of the investigator, is the patient eligible?
Determination Of Pre-entry Menopausal Status
Prior documented bilateral oophorectomy
History of at least 12 months without spontaneous menstrual bleeding
Age 55 or older with a prior hysterectomy
Age 54 or younger with a prior hysterectomy without oophorectomy (or in whom the status of the ovaries is unknown), with a documented FSH level demonstrating confirmatory elevation in the lab's postmenopausal range
Is the patient postmenopausal
Footer Module

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial