CT Scan Submission
Dayton Clinical Oncology Program
Submitted by
First Name
Last Name
Your Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Patient Name
First Name
Middle Initial
Last Name
Patient ID
*
Site CTEP ID
Date of Scan
-
Month
-
Day
Year
Date
Protocol ID
*
A021703
S1806
S1914
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Imaging Adjunctive Data for CT imaging
This protocol requires the following information to be collected with the submission of study CT scans
Time Point of CT Exam (A021703)
Baseline
On treatment (every 4 cycles)
Post-Treatment (every 8-16 weeks)
At progression
Time Point of CT Exam (S1806)
Baseline
At Week 18
At Week 30
At Week 42
At Week 54
18 Months
24 Months
30 Months
36 Months
48 Months
60 Months
Time Point of CT Exam (S1914)
Baseline
At Week 4
At Week 18
At week 30
At Week 42
At Week 54
Every 6 month until progression
At Progression
Was ORAL Contrast administered?
Yes
No
Please enter the oral contrast medium administered.
Was INTRAVENOUS contrast administered?
*
Yes
No
Is the intravenous contrast volume known?
*
Yes
No
Please enter the intravenous contrast volume (mL)
Is the contrast administration rate known?
*
Yes
No
Please enter the contrast administration rate (mL/sec)
Was a bolus tracking technique used?
*
Yes
No
Identify your sites method of contrast administration for this imaging.
Mechanical - scan has a programmed delay between injection and scan start
Manual - Injection is given and scan is started manually
Please enter the duration of the delay between injection and scan if available (sec)
Contrast injection time:
Scan Start time:
If your site's standard of care is different from the protocol recommendations, Please highlight here:
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Please enter the name of the contact for questions regarding this imaging, if not the person completing this form.
First Name
Last Name
Email
example@example.com
If additional personnel should receive a copy of this CT adjunctive data Sheet, Please enter their name below:
First Name
Last Name
Email
example@example.com
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