ID

9227

Description

Request to Terminate Patient Follow-up (RTPFU) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12401BA-52F9-4E39-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12401BA-52F9-4E39-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) null Follow-Up - Request to Terminate Patient Follow-up (RTPFU) - 2074785v3.0

English

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

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

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

Pt.ID

Data type

text

Institution ID:
Description

InstitutionNo.

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Initials: (F ML)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution:
Description

InstitutionName

Data type

text

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

Follow-upPatientRequestTerminationDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C70777
UMLS 2011AA ObjectClass
C2347790
NCI Thesaurus Property
C16960
UMLS 2011AA Property
C0030705
NCI Thesaurus Property-2
C16033
UMLS 2011AA Property-2
C1522577
NCI Thesaurus Property-3
C25496
UMLS 2011AA Property-3
C2746065
NCI Thesaurus Property-4
C48312
UMLS 2011AA Property-4
C1272683
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Reason for request:
Description

Reasonforrequest:

Data type

text

Completed by:
Description

CompletedBy

Data type

text

Date: (Year Month Day)
Description

FormCompletionDate,Original

Data type

date

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Similar models

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 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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)
Patient Initials
Item
Patient Initials: (F ML)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus 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-2)
C1522577 (UMLS 2011AA Property-2)
C25496 (NCI Thesaurus Property-3)
C2746065 (UMLS 2011AA Property-3)
C48312 (NCI Thesaurus Property-4)
C1272683 (UMLS 2011AA Property-4)
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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