CMS-10152 Interpreting Physician Scan Assessment Form

Interpreting Physician Scan Assessment Form

National Oncologic PET Registry F-18 Fluoride PET Scan

• This form is used to summarize the findings of the PET bone scan. It should be completed by the interpreting physician at the time the PET scan is interpreted.

• It must be submitted by the PET facility via Web-based data entry within 30 days of completing the PET scan.

PET FACILITY ID #:

REGISTRY CASE #:

1. OVERALL ASSESSMENT

• Normal study

• Benign skeletal abnormalities only

• Osseous metastatic disease or primary malignant bone tumor

• Unifocal

• Multifocal

• Diffuse skeletal involvement

If osseous metastatic disease or primary malignant bone tumor selected, indicate level of confidence

• Definitely present

• Probably present

• Equivocal

2. WAS COMPARISON MADE WITH PRIOR RADIONUCLIDE BONE IMAGING?

• Yes

• No

1. If yes, indicate type of study:

• Conventional bone scintigraphy

• F-18 fluoride bone PET

2. Date of prior study

1. Based on the comparison, there has been:

• No change; there is no evidence on prior or current study of metastatic disease

• Resolution of previously seen metastatic disease

• Improvement of previously seen metastatic disease

• No change in previously seen metastatic disease

• Progression of previously seen metastatic disease

3. I HAVE READ THE INTERPRETING PHYSICIAN INFORMATION STATEMENT AND:

• I DO give my consent for the inclusion of data collected for this patient in NOPR research.

• I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.

4. NAME OF PERSON SUBMITTING THIS FORM

First Name: Last Name: Date:

5. PHYSICIAN ATTESTATION OF DATA ACCURACY

By signing below I verify that, to the best of my knowledge, the information on this form is accurate.

Physician Signature: Date:

Printed Name of Physician:

Thank you for your assistance.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0968. The time required to complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

ClinicalTrials.gov Identifier NCT00868582 Version: January 05, 2012 (Page last revised January 05, 2012)