ID

9227

Descripción

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

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
Subido en

9 de enero de 2015

DOI

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Licencia

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

Inglés

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

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

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

Pt.ID

Tipo de datos

text

Institution ID:
Descripción

InstitutionNo.

Tipo de datos

text

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

Patient Initials

Tipo de datos

text

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

InstitutionName

Tipo de datos

text

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

Follow-upPatientRequestTerminationDate

Tipo de datos

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:
Descripción

Reasonforrequest:

Tipo de datos

text

Completed by:
Descripción

CompletedBy

Tipo de datos

text

Date: (Year Month Day)
Descripción

FormCompletionDate,Original

Tipo de datos

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 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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