Description:

S1007 Registration Worksheet Form - Step 2 Tamoxifen Citrate, Letrozole, Anastrozole, or Exemestane With or Without Chemotherapy in Treating Patients With Invasive RxPONDER Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90C7517A-4524-82BC-E040-BB89AD432492

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90C7517A-4524-82BC-E040-BB89AD432492

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Versions (2) ▾
  1. 8/27/12
  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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Breast Cancer NCT01272037 Registration - S1007 Registration Worksheet Form - Step 2 - 3139539v1.0

INSTRUCTIONS: All of the information on this Registration Worksheet and the Protocol Eligibility Section must be answered appropriately for a patient to be considered eligible for registration. This Registration Worksheet must be entirely filled out and referred to during the registration. Do NOT submit this worksheet as part of the patient data

Header
Swog Patient Id
Unnamed2
Unnamed5
Stratification Questions
Unnamed4
I choose to take part in the Quality of Life and Economic Analysis Study. I agree to fill out the Quality of Life Questionnaires and to allow information about my health insurance claims to be sent to researchers.
I agree to allow my study doctor, or someone approved by my study doctor, to contact me regarding future research involving my participation in this study.
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for use in research about other health problems (for example: diabetes, Alzheimer's disease, or heart disease).
Someone may contact me in the future to ask me to allow other uses of my specimens.
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Has the Southwest Oncology Group Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.16 - 5.20?

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