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Form 001: Physician’s Reporting Form Created: 2015.03.10 Last Edited: 2016.11.02 Virgin Islands Central Cancer Registry – Physician’s Cancer Report Form* Charles Harwood Complex, 3500 Estate Richmond Christiansted, VI 00820-4370 Tel. (340) 718-1311 x 3774, 3700 / Fax (340) 718-9505 / Email: viccr@doh.vi.gov Physician’s Office Information Physician Name Facility Name Address / Phone Number Patient’s Information Social Security Sex: ☐ Male ☐ Female ☐ Other: __________________ Full Name (First, Middle and Last) Physical Address (please include Estate, City, State, Zip) Phone Number Medical Record # Date and Place of Birth Marital Status 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 (where tumor arose): Histology: Behavior: ☐ Benign ☐ Borderline ☐ In Situ ☐ Malignant Laterality: ☐Right ☐ N/A ☐Left Diagnostic confirmation (check one): ☐ Histology ☐ Cytology ☐ X-ray ☐ Clinical ☐ Unknown Stage (check one): ☐ In Situ ☐ Localized ☐ Regional by direct extension ☐ Regional to LN ☐ Regional direct & LN ☐ Distant TNM: T ____ N____ M_____ Stage ______ ☐ Clinical ☐ Pathological Tumor Markers Results (example: CA 19-9, CA 125, CEA, CGA, HPV, LDH, ER, PR, Her2/neu, KRAS, AFP, PSA, hCG, etc.) Diagnostic Work Up At Diagnosis Physical examination (includes high risk factors) X-Ray / Scans / Scopes Treatment Information Type / Description Date Where performed Surgery Radiation Chemotherapy Hormone BRM Other (includes alternative medicine) Follow Up / Patient Status Completed by: Referred to: 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: *This form is intended for physician office setting ONLY. Not for hospitals or healthcare clinics. **Please, send the completed form to the USVI-CCR 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 encryption software. Microsoft encryption is not recommended. Please, attach a copy of the pathology report. Form 001: Physician’s Reporting Form Created: 2015.03.10 Last Edited: 2016.11.02 PHYSICIAN’S CANCER REPORT FORM INSTRUCTIONS Facility Information Physician Office Information Section Record the complete name, address, and telephone number of your facility or physician's office. Patient Information Patient Name Record the patient’s full name (last name, first name and middle 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. Patient's 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 of Birth Marital status Health Insurance Race Hispanic Date of Diagnosis Primary Site Laterality (paired organ) Histology Behavior / Grade Diagnostic Confirmation Please, attach copy of pathology report. Stage TNM Tumor Markers Treatment Date Last Seen Vital Status Cancer Status Record patient’s birth date in MM/DD/YYYY format. Specify patient’s marital status at time of diagnosis Record the patient’s health insurance Check off the patient’s race. Check off whether the patient considers himself or herself to be of Hispanic origin. Cancer Information Record the date the patient was first diagnosed with cancer by a recognized medical practitioner. Record in MM/DD/YYYY format. If unknown, record "unk". Record the site of origin of the tumor. Record the subsite if known (i.e. UOQ breast, LL lung). If unknown, record "unk". It is important to identify the primary site and not a metastatic site. If the site of origin is a paired organ, check the laterality. Record the histologic cell type of the tumor (i.e. mucinous adenocarcinoma; infiltrating ductal CA Check off the behavior/grade of the tumor. Check off the most reliable method used in diagnosing this cancer. Attach copy of pathology report. Use the following guidelines to determine the method: Histology: Microscopic diagnosis based on tissue specimens (i.e. biopsy, frozen section, and surgery). Cytology: Microscopic diagnosis based on cells rather than tissue (i.e. smears from sputum, bronchial washings, brushings, fine needle aspirations, etc.) Clinical: Diagnosis not supplemented with positive microscopy (i.e. made at surgical exploration, by use of an endoscope or physician’s statement that patient have cancer). X-ray-Radiological diagnosis (x-rays, scans) not microscopically confirmed. Unknown: diagnosis method is unknown. Check the stage of tumor at diagnosis (extent of disease within four months of diagnosis). Use the following categories to determine the extent at diagnosis: In Situ: tumor has not progressed through the basement membrane of the organ involved. Local: limited to site of origin; progressed through the basement membrane but not beyond the walls of the organ involved. Regional - Direct Extension: direct extension to adjacent organs or tissues. Regional - Lymph Nodes: involvement of regional lymph nodes. Distant: direct extension beyond adjacent organs or tissues, or metastases to distant sites or distant lymph nodes. Unknown: no information is available to determine extent of disease. Record the stage according to the AJCC. Specify if it is a clinical or pathological staging. Record date any result from tumor markers tests done to the patient during work up. Treatment Information 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 Record the date the patient was last seen or date of death in MM/DD/YYYY format. Check the vital status of the patient as of the date last seen. 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.