Informazione:
Errore:
ID
9227
Descrizione
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
collegamento
Keywords
versioni (2)
- 19/09/12 19/09/12 -
- 09/01/15 09/01/15 - Martin Dugas
Caricato su
9 gennaio 2015
DOI
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Licenza
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
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.
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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.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
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)
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)
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)
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