Visit Date

The Visit Date is optional on this case report form. Hit the "Tab" key to leave it empty and move to the Date of Vitals field.

DD-MMM-YYYY

Day in Course^(d)

Indicates the day since the beginning of course initiation. Derived from the course initiation start date.

5 digits

Start Date^(m)

Enter the start date of the radiation therapy.

DD-MMM-YYYY

Start Time

Enter the start time of the radiation therapy.

HH(24):MM

Stop Date^(m)

Enter the date of the last dose of the radiation therapy.

DD-MMM-YYYY

Stop Time

Enter the stop time of the radiation therapy.

HH(24):MM

Radiation Type^(m)

Select the type of radiation therapy, e.g.: "proton beam", "external beam" or "implant".

Use pick list.

Other, Specify

Enter an explanation when ‘Other, Specify’ is selected as a ‘Radiation Type’

100 character

Radiation Field

Select the site of the radiation therapy.

Use pick list.

Dose^(m)

State the total radiation dose the patient received during the treatment period.

8 characters

Dose UOM^(m)

Select the radiation dose units of measurement (e.g. cGy or rad, or cSv or rem).

Use pick list.

Dose per Fraction

Enter the fractionated dose of radiation therapy administered to a treatment field or site according to protocol.

5 digits

Total # of Fractions

Enter the number of dose-portions or fractions of radiation therapy actually administered.

4 digits

Elapsed Days

Enter the actual number of days radiation therapy was administered.

30 digits

Tx Delivery Location

Select the institute where the radiation therapy was administered.

Use pick list.

RAD01,
RAD02

Date is in the future.

Enter a date that is equal to or earlier than the current date.

RAD03

Stop Date/Time is greater than Start Date/Time.

Correct the Start Date/Time or Stop Date/Time.

RAD04

Radiation Type 'Other Specify' and 'Other, Specify' field are not present together.

Enter ‘Other Specify’ if ‘Other Specify’ is selected as Radiation Type.

RAD1002

Day in Course

Derived from the respective course initiation start date.