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

  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT00085124 Toxicity - CALGB: 10201 ADVERSE EVENT FORM - 2070578v3.0

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
Are data Amended?
Treatment Phase
Was an AER/ADR filed with Central Office based on an event reported below?
Expected Adverse Events
Were there any other events (Hematologic grade 4-5 only or Non-Hematologic grade 3-5 only) noted during this time period?
Ccrr Module For Calgb: 10201 Adverse Event Form

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