CMS-10152 Diagnosis of Suspected Osseous Metastasis Form

Diagnosis of Suspected Osseous Metastasis Form

National Oncologic PET Registry F-18 Fluoride PET Scan

PET FACILITY ID #:

REGISTRY CASE #:

PATIENT NAME:

Your patient had a PET scan on: mm/dd/yyyy.

You previously indicated that the PET scan was done for diagnosis of suspected osseous metastatic disease in a patient without a pathologic diagnosis of cancer.

• After reviewing the PET report, please complete the following questions and return the form to the PET Facility.

• This form must be entered into the database within 30 days of the PET scan.

1. IN LIGHT OF THE PET FINDINGS, WHAT IS YOUR CURRENT ASSESSMENT OF THE LIKELIHOOD OF OSSEOUS METASTATIC DISEASE?

• Definitely present

• Probably present

• Uncertain

• Probably not present

• Definitely not present

2. SINCE OBTAINING THE SCAN, HAS A TISSUE BIOPSY BEEN PERFORMED OF A SUSPICIOUS OSSEOUS SITE?

• Yes

• No

If yes, indicate whether the bone biopsy results are:

• Negative

• Positive

• Pending

3. HAS A PATHOLOGIC DIAGNOSIS OF CANCER BEEN CONFIRMED FROM ANY SITE?

• Yes

• No

4. DID THE PET SCAN ENABLE YOUR PATIENT TO AVOID ANY

1. noninvasive diagnostic tests?

• Yes

• No

2. any invasive procedures?

• Yes

• No

5. I HAVE READ THE REFERRING 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.

6. NAME OF PERSON SUBMITTING THIS FORM

First Name: Last Name: Date:

7. 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)