Radiation Therapy Oncology Group Cover Sheet 1 Brachytherapy Cosrnesis Questionnaire

If this is a revised or corrected form, indicate by checking box.

RTOG Study

9517

Case # Case # Inst # I.D. #

Intergroup Study institution Patient Name

INSTRUCTIONS: The cover sheet is the first page of the brachytherapy cosmesis questionnaire. The cover sheet DE is completed by the clinical staff and a separate copy attached to the questionnaire completed by the patient, the radiation oncologist and the surgeon. If a questionnaire was missed, complete the cover sheet only and Q.1,3A and the calendar date of the missed questionnaire. Cosmetic results will be assessed by the patient, the surgical oncologist, and the radiation oncologist. Dates are recorded mrn/dd/yyyy unless otherwise specified. 3 0 If the evalua- 0 TIME POINT OF ASSESSMENT tion was not done, complete this section, sign, date and submit to HQ. A separate 6 month followup 1 cover sheet i s required for each form. 2 12 month followup 3 Other, specify REASON QUESTIONNAIRE NOT COMA PLETED WAS QUESTIONNAIRE COMPLETED 1 Patient unable to complete questionnaire 1 No due to illness 2 Yes 2 Patient refusedto complete any items Reason for refusal IF ANY QUESTIONNAIRE ITEMS ARE ANSWERED, COMPLETE THIS SECTION, 3 Patient (family, significant other) could not SIGN, DATE AND ATTACH COVER SHEET be contacted TO FRONT OF QUESTIONNAIRE BEFORE 4 Reason evaluation not done by Radiation SUBMllTlNG Oncologist

2A

TYPE 1 2 3 Surgeon Radiation Oncologist Patient

Reason evaluation not done by Surgical Oncologist Other reason, explain

28

DATE QUESTIONNAIRE COMPLETED BY PATIENT OR SLlRGlCAL ONCOLOGIST, RADIATION ONCOLOGIST DATE PATIENT COMPLETED THE QUESTIONNAIRE OR CALENDAR DATE OF MISSED ASSESSMENT DATE THE SURGICAL ONCOLOGIST COMPLETED THE FORM OR CALENDAR DATE OF MISSED ASSESSMENT DATE THE RADIATION ONCOLOGIST COMPLETED THE FORM OR CALENDAR DATE OF MISSED ASSESSMENT

I / -

1 1 --

1 1 --

COMMENTS

1 1 Signature

Date

9517

6/97

1of2