CMS-10152 Report Submission Form

Report Submission Form

National Oncologic PET Registry F-18 Fluoride PET Scan

This form is used to transmit the PET Report. It is completed by the PET facility via Web-based data entry within 30 days of completing the PET scan..

PET FACILITY ID #:

REGISTRY CASE #:

1. DATE SCAN COMPLETED:

2. DATE PET REPORT COMPLETED:

3. INTERPETING PHYSICIAN INFORMATION Pull Down Menu of Interpreting Physicians

4. PET REPORT (You must enter the report as free text. No other entry method is accepted.)

Free text

Cut and paste from Microsoft Word document or other text document. You must enter the complete text of the PET report, pasting or typing all pages.

5. AFTER BEING GIVEN THE NOPR PATIENT INFORMATION STATEMENT, DID THE PATIENT CONSENT TO HAVE HIS OR HER DATA USED FOR NOPR RESEARCH?

• Yes

• No

6. NAME OF PERSON SUBMITTING THIS FORM

First Name: Last Name: Date:

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