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Form 002: Hospice’s Reporting Form Created: 2015.03.25 Edited: 2016.06.28 Virgin Islands Central Cancer Registry – Hospice Cancer Report Form* Charles Harwood Complex, 3500 Estate Richmond Christiansted, VI 00820-4370 Tel. (340) 718-1311 x 3774, 3793, 3700 / Fax (340) 718-9505 / Email: viccr@doh.vi.gov Diagnostic Work Up at Diagnosis Physical examination X-Ray / Scans / Scopes *This form is intended for hospice care setting ONLY. Not for physicians, hospitals or healthcare clinics. **Please, send the completed form to the VICCR via e-mail to: viccr@doh.vi.gov To protect our patient’s privacy and to comply with HIPAA regulations the attached forms must be encrypted and password protected using an encryption software. Microsoft encryption is not recommended. Hospice Care Facility Information Facility Name Referred to: Physician Name Patient’s Information Full Name (First, Middle and Last) Social Security Sex: ☐ Male ☐ Female ☐ Other: __________________ Physical Address (please include Estate, City, State, Zip) Phone Number Medical Record # Date and Place of Birth Marital Status Health Insurance Race: ☐ Caucasian / White ☐ Black ☐ Asian ☐ Native American ☐ Other ☐ Unknown ***For Hispanic patients, please select a race. Hispanic: ☐ Yes ☐ No ☐ Other Cancer Information Date of Diagnosis Primary Site (e.g.: colon, breast, prostate, etc.) Histology (adenocarcinoma, squamous carcinoma, lymphoma) Place of diagnosis Treatment Information Type / Description Date Where performed Surgery Radiation Chemotherapy Hormone BRM Other (includes alternative medicine) Additional Comments Follow Up / Patient Status Completed by Date of last contact: Vital Status: □ Alive □ Dead Cancer Status: □ evidence of CA □ no evidence of CA If expired; please provide date and place of death: Name: Date: Form 002: Hospice’s Reporting Form Created: 2015.03.25 Edited: 2016.06.28 HOSPICE’S CANCER REPORT FORM INSTRUCTIONS Facility Information Reporting Facility Section Record the complete name, address, and telephone number of your facility or physician's office. Patient Information Name Record the patient’s full name. Social Security Number Record the patient's social security number. Do not record a spouse's number. Sex Check off the patient’s sex/gender. Physical Address Record patient’s permanent home address at time of diagnosis, not a temporary relocation for treatment. Street address takes priority over post office box number. Phone Number Record the patient’s phone number Medical Record Number Record the patient’s medical record number Date and Place of Birth Record patient’s birth date in MM/DD/YYYY format. Also record the place of birth. Marital status Specify patient’s marital status at time of diagnosis Health Insurance Record the patient’s health insurance Race Check off the patient’s race. Hispanic Origin Check off whether the patient considers himself or herself to be of Hispanic origin. Cancer Information Date of Diagnosis Record the date the patient was first diagnosed with cancer by a recognized medical practitioner. Record in MM/DD/YYYY format. If unknown, record "unknown" Primary Site Record the site of origin of the tumor. Record the subsite if known (i.e., UOQ breast, LL lung). If unknown, record "unknown". It is important to identify the primary site and not a metastatic site. Histology Record the histologic cell type of the tumor (ie. mucinous adenocarcinoma; infiltrating ductal CA Place of Diagnosis If the patient was diagnosed elsewhere, record the facility name and location. If unknown, record "unknown" Treatment Information Treatment Record all first-course treatment that the patient received. Do not record second-course treatment. First-course treatment includes all cancer-directed treatment modalities given by clinicians at the time of diagnosis. When recording treatment, write the type of treatment, the date the treatment was received or began and where performed. Follow Up / Patient Status Date Last Seen Record the date the patient was last seen or date of death in MM/DD/YYYY format. Vital Status Check the vital status of the patient as of the date last seen. Cancer Status Check the patient's cancer status as of the date the patient was last known to be alive or dead.. If Expired, Place of Death If patient expired, record the place of death. If unknown, record "unk". Cause of Death If patient expired, record the cause of death. If unknown, record "unk". Completed by Form Completed By Record the full name of the person completing the form. Date Completed Record the date completed.