CALGB 80702 Adverse Event (AE) Form (CTCAE v.4) Oxaliplatin, Leucovorin Calcium, and Fluorouracil With or Without Celecoxib in Treating Patients With Stage III Colon Cancer Previously Treated With Surgery Source Form: NCI FormBuilder:


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  1. 8/27/12
  2. 1/9/15
  3. 1/9/15
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January 9, 2015

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Colorectal Cancer NCT01150045 Toxicity - CALGB 80702 Adverse Event (AE) Form (CTCAE v.4) - 2969642v1.0

INSTRUCTIONS: Complete and submit this 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. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. Use NCI CTCAE v4.x or most current version with MedDRA codes posted at to grade each adverse event. Grade = -1 if category not evaluated. Grade = 0 if category evaluated but event not reported. AE is defined as adverse event. TREATMENT ATTRIBUTION CODES: 1 = unrelated, 2 = unlikely, 3 = possible, 4 = probable, 5 = definite

Are data amended
Has an AdEERS been filed (with Central Office based on an event reported below)
Expected Adverse Events
CTC AE Attribution Code (AE is defined as adverse event)
CTC AE Attribution Code (AE is defined as adverse event)
CTC AE Grade
CTC AE Grade

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