CALGB: 10201 Treatment FORM Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder:


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  2. 1/9/15
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January 9, 2015

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Leukemia NCT00085124 Treatment - CALGB: 10201 Treatment FORM - 2031608v3.0

Instructions: Complete and submit thie form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Cirlce amended items and check "Amended data" box to teh right. If submitting by mail, retain a copy for your records and send the original form for mazimum clarity in transmission and fax to 919-416-4990. If submistting electronically, click the Send button when you have completed the PDF version of the form.

Calgb Form
Treatment Phase Information
Treatment Phase (Mark one with an X)
Leukemia Treatment Plan
Did the patient receive any protocol treatment?
If the treatment ended this period, reason treatment ended or not given (Mark one with an X)
Were there any dose modifications or additions/omissions to protocol treatment (Mark one with an X)
Ccrr Module For Calgb: 10201 Treatment Form

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