Description:

E2205 Registration Worksheet (step 1) Chemotherapy, Radiation Therapy, and Cetuximab Followed by Surgery, Docetaxel, and Cetuximab in Treating Patients With Esophageal Cancer or Gastroesophageal Junction Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4E4AEBDF-A595-00B2-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4E4AEBDF-A595-00B2-E044-0003BA3F9857

Keywords:
Versions (2) ▾
  1. 9/19/12
  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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Esophageal Cancer NCT00551759 Eligibility - E2205 Registration Worksheet (step 1) - 2753343v1.0

No Instruction available.

  1. StudyEvent: E2205 Registration Worksheet (step 1)
    1. No Instruction available.
Eligibility
Has the eligibility checklist been completed
In the opinion of the investigator, is the patient eligible?
Has written informed consent been obtained
Has HIPAA authorization been obtained
ECOG Performance Status
Clinical Stage
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
Someone may contact me in the future to ask me to allow other uses of my specimens.
If an ECOG patient is to receive radiation therapy, will it be given at the registering institution
Patient Demographics / Pre-treatment Characteristics
Patient's Sex
Patient Race (check all that applyU.S. and Canada only)
Method of payment (check one)