Office of Data Quality, OS-200 Dana-Farber/Harvard Cancer Center, (OS 200), , MA 02115 TEL: (617) 632-3761 Email: TREATMENT ENDED & OFF STUDY FORM To be completed when a subject completes protocol treatment and/or when the subject comes off-study. Please fill INSTRUCTIONS: out all the information requested below and email to the ODQ registrars at STUDY SUBJECT INFORMATION (Last, First) Subject Name Hospital I.D. # Protocol Number *************************************************************************** Date Treatment Ended (Last day of protocol treatment; i.e., chemotherapy, radiotherapy) Reason Specify Toxicity I DLT Y/N If Reason 3– Date of If Reason 4 – Other (please describe) If Reason 98 – Will the subject continue on follow-up? (Y/N) *************************************************************************** Date Off Study (Last day patient was being followed on protocol) Leave blank if patient remains in follow-up. Reason Date of Death If Reason 4– Specify Toxicity Phase I DLT Y/N If Reason 5– (please describe) If Reason 98 – *************************************************************************** Completed By Phone# Date
Office of Data Quality, OS-200 Dana-Farber/Harvard Cancer Center, (OS 200), , MA 02115 TEL: (617) 632-3761 Email: TREATMENT ENDED & OFF STUDY FORM INSTRUCTIONS: To be completed when a subject completes protocol treatment and/or when the subject comes off-study. Please fill out all the information requested below and email to the ODQ registrars at STUDY SUBJECT INFORMATION Subject Name (Last, First) Hospital I.D. # Protocol Number *************************************************************************** Date Treatment Ended (Last day of protocol treatment; i.e., chemotherapy, radiotherapy) Reason If Reason 3– Specify Toxicity I DLT Y/N If Reason 4 – Date of If Reason 98 – Other (please describe) Will the subject continue on follow-up? (Y/N) *************************************************************************** Date Off Study (Last day patient was being followed on protocol) Leave blank if patient remains in follow-up. Reason If Reason 4– Date of Death If Reason 5– Specify Toxicity Phase I DLT Y/N If Reason 98 – (please describe) *************************************************************************** Completed By Phone# Date