Generic Ctc Version 2.0 Data Collection Form
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1
2
3National Institutes of Health
Division of Cancer Treatment and Diagnosis
National Cancer Institute
Cancer Therapy Evaluation Program
Generic CTC Version 2.0 Data Collection Form
Please Print or Type
Protocol No.:
Patient ID No.:
Course No.:
*
Date of Event
Category/Toxicity
Grade
Attribution
Yes
No
ALLERGY/IMMUNOLOGY
Allergic reaction/hypersensitivity (including drug fever)
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
AUDITORY/HEARING
1 2 3 4 5
1 2 3 4 5
Yes
No
BLOOD/BONE MARROW
Hemoglobin (Hgb)
1 2 3 4 5
1 2 3 4 5
Leukocytes (total WBC)
1 2 3 4 5
1 2 3 4 5
Neutrophils/granulocytes (ANC/AGC)
1 2 3 4 5
1 2 3 4 5
Platelets
1 2 3 4 5
1 2 3 4 5
Transfusion: platelets
3 4 5
1 2 3 4 5
Transfusion: pRBCs
3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
CARDIOVASCULAR (ARRHYTHMIA)
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
CARDIOVASCULAR (GENERAL)
Cardiac-ischemia/infarction
1 2 3 4 5
1 2 3 4 5
Cardiac left ventricular function
1 2 3 4 5
1 2 3 4 5
Hypotension
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
COAGULATION
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
CONSTITUTIONAL SYMPTOMS
Fatigue
1 2 3 4 5
1 2 3 4 5
Weight loss
1 2 3
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Unrelated
1 The adverse event (toxicity) is not related to the investigational agent(s).
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Attribution Key:
Revised 6/11/98
Unlikely
2 The adverse event (toxicity) is doubtfully related to the investigational agent(s).
Possible
3 The adverse event (toxicity) may be related to the investigational agent(s).
Probable
4 The adverse event (toxicity) is likely related to the investigational agent(s).
Definite
5 The adverse event (toxicity) is clearly related to the investigational agent(s).
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