11-c-0125 irb approval document date 021617
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10.2 APPENDIX B: GLOBAL SCORING OF CHRONIC GVHD107 SCORE 0 SCORE 1 SCORE 2 SCORE 3 PERFORMANCE SCORE: (Appendix H) KPS ECOG LPS
SKIN Clinical features:
% BSA involved
<NO
OR OROR
MOUTH
with
with
EYES
OR
WITHOUT
OROR
GI TRACT
OR
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SCORE 0 SCORE 1 SCORE 2 SCORE 3 LIVER
LUNGS*
FEV1 DLCO
OR
OR
OR
OR
JOINTS AND FASCIA
AND
OR
AND
WITH AND
GENITAL TRACT AND
AND
WITH
AND
*"AP#may#be#elevated#in#growing#children,#and#not#reflective#of#liver#dysfunction"
Other"indicators,"clinical"manifestations"or"complications"related"to"cGVHD"(check"all"that"apply"and"assign"a"score"to"its"severity"based"on"its"functional"
impact"(none"–"0,"mild"–"1,"moderate"–"2,"severe"–"3):#___Esophageal#stricture#or#web# ___Pericardial#Effusion# # ___Pleural#Effusion(s)#
___Ascites#(serositis)# ___Nephrotic#syndrome# # ___Peripheral#Neuropathy#
___Myasthenia#Gravis# ___Cardiomyopathy# # ___Eosinophilia#>#500μl#___Polymyositis## # ___Cardiac#conduction#defects# ___Coronary#artery#involvement#
___Platelets#<100,000/μl## ___Progressive#onset#
___OTHERS:"
##
#
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http://www.asco.org/quality -guidelines/informed-consent-chemotherapy-administration 9/2/07
[Name of Physician Practice]
Consent to Chemotherapy
(check all that apply; additional space provided for physician comments)
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© American Society of Clinical Oncology 2008. All rights reservedInformed consent is an ongoing communication process. Consent forms, including this template, are in no way intended to replace or
limit, in whole or in part, the thorough exchange of information between physicians and patients, and should not be used in this manner. Though the consent template reflects basic informed consent requirements, no single consent form could be appropriate for
all patients. It is the responsibility of the treating physician or other health care provider to tailor the consent process to meet individual patient’s needs. Because the consent form can include confidential information about a patient’s medical record and
treatment regimen, it should be used or disclosed only in accordance with federal and state privacy laws. Laws governing informed consent vary from state to state and may change over time. Before using the template, health care providers are advised to consult legal counsel to determine whether all required elements of informed consent are addressed. Use of this consent template is entirely
voluntary and does not imply ASCO’s endorsement of any physician practice, treatment regimen, or product. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related any use of this Template, any changes made to
this Template by the user, or any errors or omissions.
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