Generic Ctc Version 2.0 Data Collection Form Page 2
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1
2
3*
Attribution
Date of Event
Category/Toxicity
Grade
Yes
No
DERMATOLOGY/SKIN
Alopecia
1 2
1 2 3 4 5
Rash/desquamation
1 2 3 4 5
1 2 3 4 5
Urticaria (hives, welts, wheals)
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
Yes
No
ENDOCRINE
1 2 3 4 5
1 2 3 4 5
Yes
No
GASTROINTESTINAL
Anorexia
1 2 3 4 5
1 2 3 4 5
Dehydration
1 2 3 4 5
1 2 3 4 5
Diarrhea
1 2 3 4 5
1 2 3 4 5
Dysphagia, esophagitis, odynophagia (painful swallowing)
1 2 3 4 5
1 2 3 4 5
Nausea
1 2 3
1 2 3 4 5
Stomatitis/pharyngitis (oral/pharyngeal mucositis)
1 2 3 4 5
1 2 3 4 5
Vomiting
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
HEMORRHAGE
Hemorrhage/bleeding with grade 3 or 4 thrombocytopenia
1
3 4 5
1 2 3 4 5
Hemorrhage/bleeding without grade 3 or 4
1
3 4 5
1 2 3 4 5
thrombocytopenia
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
HEPATIC
Bilirubin
1 2 3 4 5
1 2 3 4 5
GGT
1 2 3 4 5
1 2 3 4 5
SGOT (AST)
1 2 3 4 5
1 2 3 4 5
SGPT (ALT)
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
INFECTION/FEBRILE NEUTROPENIA
Catheter-related infection
1 2 3 4 5
1 2 3 4 5
Febrile neutropenia (fever of unknown origin without
3 4 5
1 2 3 4 5
clinically or microbiologically documented infection.
9
(ANC <1.0 x 10
/L, fever > 38.5)
Infection (documented clinically or microbiologically) with
3 4 5
1 2 3 4 5
9
grade 3 or 4 neutropenia. (ANC < 1.0 x 10
/L)
Infection without neutropenia
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
Unrelated
1 The adverse event (toxicity) is not related to the investigational agent(s).
Page 2 of 3
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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