Instructions: Complete this form to request permission from ACOSOG to cease follow-up for a patient. Enter the date of the request in the designated boxes below and write the reason for the request LEGIBLY on the lines provided. Sign and date the bottom of the form. Fax this form to the ACOSOG Coordinating Center at 919-668-8466 as soon as possible. Your request will be reviewed and a determination will be made by ACOSOG. A response to your request will be e-mailed to you shortly thereafter. If approved, an ?Early Termination Authorization Number? will be included in this e-mail. This number should be entered in the designated field on the Termination of Patient Follow-up (TPFU) form, which should be completed and submitted ONLY upon receiving approval from ACOSOG. Please retain the e-mail authorization in the study record.

1 moduli

StudyEvent: Request to Terminate Patient Follow-up (RTPFU)
1. Instructions: Complete this form to request permission from ACOSOG to cease follow-up for a patient. Enter the date of the request in the designated boxes below and write the reason for the request LEGIBLY on the lines provided. Sign and date the bottom of the form. Fax this form to the ACOSOG Coordinating Center at 919-668-8466 as soon as possible. Your request will be reviewed and a determination will be made by ACOSOG. A response to your request will be e-mailed to you shortly thereafter. If approved, an ?Early Termination Authorization Number? will be included in this e-mail. This number should be entered in the designated field on the Termination of Patient Follow-up (TPFU) form, which should be completed and submitted ONLY upon receiving approval from ACOSOG. Please retain the e-mail authorization in the study record.

Ccrr Module For Request To Terminate Patient Follow-up (rtpfu)

Descrizione

Ccrr Module For Request To Terminate Patient Follow-up (rtpfu)

Patient ID (Pt. ID issued during registration or previously issued patient ID)

Descrizione

Pt.ID

Tipo di dati

text

Institution ID:

Descrizione

InstitutionNo.

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

Patient Initials: (F ML)

Descrizione

PatientInitialsName

Tipo di dati

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS 2011AA ValueDomain: C1547383

NCI Thesaurus ObjectClass: C16960

UMLS 2011AA ObjectClass: C0030705

NCI Thesaurus Property: C25536

UMLS 2011AA Property: C1555582

Institution:

Descrizione

InstitutionName

Tipo di dati

text

Date of site request to terminate patient follow-up: (Month Day Year)

Descrizione

Follow-upPatientRequestTerminationDate

Tipo di dati

date

Alias

NCI Thesaurus ObjectClass: C70777

UMLS 2011AA ObjectClass: C2347790

NCI Thesaurus Property: C16960

UMLS 2011AA Property: C0030705

NCI Thesaurus Property: C16033

UMLS 2011AA Property: C1522577

NCI Thesaurus Property: C25496

UMLS 2011AA Property: C2746065

NCI Thesaurus Property: C48312

UMLS 2011AA Property: C1272683

NCI Thesaurus ValueDomain: C25164

UMLS 2011AA ValueDomain: C0011008

Reason for request:

Descrizione

Reasonforrequest:

Tipo di dati

text

Completed by:

Descrizione

CompletedBy

Tipo di dati

text

Date: (Year Month Day)

Descrizione

FormCompletionDate,Original

Tipo di dati

date

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Instructions: Complete this form to request permission from ACOSOG to cease follow-up for a patient. Enter the date of the request in the designated boxes below and write the reason for the request LEGIBLY on the lines provided. Sign and date the bottom of the form. Fax this form to the ACOSOG Coordinating Center at 919-668-8466 as soon as possible. Your request will be reviewed and a determination will be made by ACOSOG. A response to your request will be e-mailed to you shortly thereafter. If approved, an ?Early Termination Authorization Number? will be included in this e-mail. This number should be entered in the designated field on the Termination of Patient Follow-up (TPFU) form, which should be completed and submitted ONLY upon receiving approval from ACOSOG. Please retain the e-mail authorization in the study record.

1 moduli

StudyEvent: Request to Terminate Patient Follow-up (RTPFU)
1. Instructions: Complete this form to request permission from ACOSOG to cease follow-up for a patient. Enter the date of the request in the designated boxes below and write the reason for the request LEGIBLY on the lines provided. Sign and date the bottom of the form. Fax this form to the ACOSOG Coordinating Center at 919-668-8466 as soon as possible. Your request will be reviewed and a determination will be made by ACOSOG. A response to your request will be e-mailed to you shortly thereafter. If approved, an ?Early Termination Authorization Number? will be included in this e-mail. This number should be entered in the designated field on the Termination of Patient Follow-up (TPFU) form, which should be completed and submitted ONLY upon receiving approval from ACOSOG. Please retain the e-mail authorization in the study record.

Name

genere

Description | Question | Decode (Coded Value)

Tipo di dati

Alias

CCRR MODULE

Item Group

Ccrr Module For Request To Terminate Patient Follow-up (rtpfu)

Pt.ID

Item

Patient ID (Pt. ID issued during registration or previously issued patient ID)

text

InstitutionNo.

Item

Institution ID:

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)

PatientInitialsName

Item

Patient Initials: (F ML)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)

InstitutionName

Item

Institution:

text

Follow-upPatientRequestTerminationDate

Item

Date of site request to terminate patient follow-up: (Month Day Year)

date

C70777 (NCI Thesaurus ObjectClass)
C2347790 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus Property)
C0030705 (UMLS 2011AA Property)
C16033 (NCI Thesaurus Property)
C1522577 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
C48312 (NCI Thesaurus Property)
C1272683 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

Reasonforrequest:

Item

Reason for request:

text

CompletedBy

Item

Completed by:

text

FormCompletionDate,Original

Item

Date: (Year Month Day)

date

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