Description:

S1011 Registration Worksheet Step 1 (#23645) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9386ADF9-F927-860A-E040-BB89AD4354A2

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9386ADF9-F927-860A-E040-BB89AD4354A2

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Versions (2) ▾
  1. 8/26/12
  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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Bladder Cancer NCT01224665 Registration - S1011 Registration Worksheet Step 1 (#23645) - 3152651v1.0

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
SWOG Patient ID Status
Demography
Unnamed2
Unnamed5
Unnamed4
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.
Unnamed 7
Has the SWOG Registration Worksheet been completed entirely and is the patient eligible according to the current version of protocol section 5.0?