ECOG Long-Term Follow-up Form (E2100) Source Form: NCI FormBuilder:


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January 22, 2015

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Long-Term Follow-up Form (ECOG E2100)

Form No. 1555

  1. StudyEvent: ECOG Long-Term Follow-up Form (E2100)
    1. Form No. 1555
Are data amended?
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
Notice Of Progression
Has the patient developed a first progression that has not been previously reported?
Did a physician make a formal diagnosis of progressive disease?
Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3) long term toxicity that has not been previously reported? (NOTE: Do not report toxicities occurring after start of non-protocol therapy.)
Non-protocol Therapy
Has the patient received any non-protocol cancer therapy prior to first progression (not previously reported)?

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