DCOP TREATMENT DATA COVERSHEET
(Submit with each treatment data submission)
Nurse
*
Email
*
example@example.com
Patient
*
Patient ID
*
Study
*
Cycle/Timeframe
*
Review all data prior to submission to include the following (as required):
All data with patient name and date of service
All corrections made to data with one line through error, initials & date
Toxicity sheet completed with CTCAE terms, grade, and attribution *Check CTCAE version per the protocol
CT/MRI/PET scan reports/disc, labeled with pt identifiers
H&P (include all done for this timeframe, including Day 1 of next cycle)
Infusion sheet with treatment start date, start and stop times
Investigational Drug Accountability Records Form (DARF)
Lab reports (include all done for this timeframe)
Pill diary
QOL
Research Specimens, per protocol, and corresponding shipping documents
Study calendar with assessment dates, signed and dated by ORN
Current med list
Treatment Orders
RT data/disc
Notes:
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