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Appendices

  1. Data Submission Checklist
  2.  Eligibility Checklist   
  3. Performance Status
  4. Med Watch    
  5.  Study Parameters Table   
  6. TNM Nomenclature and Staging   
  7.  Baseline Breast Cancer Risk Study Questionnaire
  8.  Follow-Up Breast Cancer Study Risk Questionnaire
  9.  Modified Skindex-16 QOL Questionnaire
  10.  Appendix 10A - B39 QOL In Tact     Appendix 10B - B39 QOL Chest Wall
  11. RTOG SOMA Criteria
  12.  Instructions for Photographs
  13.  Breast Chest Wall RT Completion Form
  14.  ONS Criteria for Acute Radiation Induced Skin Reaction
  15.  FACT- B*
  16.  Specimen Collection and Shipping Instructions
  17. CTSU Participation Procedures
  18. Flow Sheet / Addenda 

     Combined Appendices   


Spanish Versions:
7. Baseline Breast Cancer Risk Study Questionnaire 
8. Follow-Up Breast Cancer Study Risk Questionnaire  
9.  Modified Skindex-16 QOL Questionnaire 
10. Appendix 10A - B39 QOL In Tact     Appendix 10B - B39 QOL Chest Wall

Helpful Tool
 Site Flyer

*1.To obtain this copyrighted form, please enter CCRBIS.
 2. Click on “login CCRBIS” at the top right of the CCRBIS screen.
 3. Type Username and Password.
 4. Click on “login.”
 5. Click on “Information” on the left side of the green bar at the top of the page.
 6. Click the "97609 Forms" box to obtain the FACT-B
 7. Print.
Contact June Fletcher-Steede at jsteede@wakehealth.edu for password information.

 

Quick Reference

Research Base

Phone 336-716-0891
Fax 336-716-6275

E-mail
resbase@wakehealth.edu

Medical Center Boulevard, 525@Vine 4th floor
Box 573152
Winston-Salem, NC 27157
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Last Updated: 03-15-2016
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.

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