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 Formulare

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)

Beschreibung

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

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

Beschreibung

Pt.ID

Datentyp

text

Institution ID:

Beschreibung

InstitutionNo.

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25337

UMLS 2011AA ValueDomain: C0237753

Patient Initials: (F ML)

Beschreibung

Patient Initials

Datentyp

text

Alias

NCI Thesaurus ValueDomain: C25191

UMLS CUI-1: C2986440

NCI Thesaurus ObjectClass: C16960

NCI Thesaurus Property: C25536

Institution:

Beschreibung

InstitutionName

Datentyp

text

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

Beschreibung

Follow-upPatientRequestTerminationDate

Datentyp

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:

Beschreibung

Reasonforrequest:

Datentyp

text

Completed by:

Beschreibung

CompletedBy

Datentyp

text

Date: (Year Month Day)

Beschreibung

FormCompletionDate,Original

Datentyp

date

Zum Seitenanfang zurückkehren

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 Formulare

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

Typ

Description | Question | Decode (Coded Value)

Datentyp

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)

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

Zum Seitenanfang zurückkehren

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