"",Version No.: 07/01
Participant ID Number,
"Prostate, Lung, Colorectal and Ovarian",
Cancer Screening Trial,
MEDICAL RECORD ABSTRACT FORM,
DIAGNOSTIC EVALUATION – COLORECTUM (DEC3/DCQ3),
1. Date Abstracted: ___________________________________________,
Month Day Year,
2. Abstractor ID#: ___ ___ ___ ___,
3. Nosologist ID: ___ ___ ___ ___,
4. CTR ID: ___ ___ ___ ___,
5. Study Year T0-T13: ___ ___,
6. Purpose of Abstract:,
〇 Initial abstract,
〇 Re-abstract for QA,
7. Multiple Primary Cancer #: (Select 2 through 9),
(GO TO A.7),
FOR OFFICE USE ONLY,
8. Form Processing (MARK RESPONSES AS STEPS ARE COMPLETED),
〇 Form Receipted into SMS,
〇 Manual Review Completed,
Data Entry of Non-Scannable Items:,
〇 Completed,
〇 None Required,
Data Retrieval:,
〇 Attempted,
〇 None Required,
Disposition:,
〇 Interim Complete (ICM),
〇 Final Complete (FCM),
〇 Final Incomplete (FIC),