Generic Ctc Version 2.0 Data Collection Form Page 3
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1
2
3*
Attribution
Date of Event
Category/Toxicity
Grade
Yes
No
LYMPHATICS
1 2 3 4 5
1 2 3 4 5
Yes
No
METABOLIC/LABORATORY
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
MUSCULOSKELETAL
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Yes
No
NEUROLOGY
Neuropathy-cranial
2 3 4 5
1 2 3 4 5
Neuropathy-motor
1 2 3 4 5
1 2 3 4 5
Neuropathy-sensory
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
OCULAR/VISUAL
1 2 3 4 5
1 2 3 4 5
Yes
No
PAIN
1 2 3 4 5
1 2 3 4 5
Yes
No
PULMONARY
1 2 3 4 5
1 2 3 4 5
Yes
No
RENAL/GENITOURINARY
Creatinine
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
SECONDARY MALIGNANCY
1 2 3 4 5
1 2 3 4 5
Yes
No
SEXUAL/REPRODUCTIVE FUNCTION
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 3 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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