English	French	Notes	Complete/Exclude
DATE OF LAST CONTACT:  			
TUMOR STATUS:  			
ICD Revision:  			
Place of Death:  			
Care Center at Death: 			
Autopsy:  			
Autopsy Date/Time:  			
Autopsy No:  			
ICD Cause of Death:  			
Cause of Death/Cancer:  			
Date of Death:  			
Path/autopsy: 			
Religion:  			
Marital Status at Dx:  			
Occupation:  			
   Last Date:  			
Type of Tobacco user:  			
     YR. Quit Tobacco Use:  			
     Yrs. of Alcohol Use:  			
     Drinks per-day:  			
     Yr. Quit Drinking:  			
Family Member with Cancer:  			
Cancer:  			
Primary Surgeon:  			
Managing Physician:  			
Following Physician:  			
Other Physician 3:  			
Other Physician 4:  			
DX Date:  			
Class of Case:  			
Type of Reporting Source:  			
Histology:  			
Dx Facility:  			
Text Histology:  			
Grade:			
Tumor Marker 2:			
ICDO-Site:  			
Referring Facility:  			
Laterality:  			
Transfer Facility:  			
DX Confirmation:  			
Primary Payer at Diagnosis:  			
IP/OP status:  			
Screening Result:  			
Screening Date:  			
Presentation at Cancer Conference:  			
Date of Cancer Conference:  			
Referral to Support Services:  			
Site/Gp:  			
      Primary Sequence No:  			
Text-Primary Site Title:  			
Text-Dx Proc-PE: 			
Text-Dx Proc-X-ray/scan: 			
Text-Dx Proc-Op: 			
Text-Dx Proc-Lab Tests: 			
Text-Dx Proc-Scopes: 			
Text-Dx Proc-Path: 			
Text Primary Site:  			
Text Dx Proc-Phys.Exam: 			
Text Dx Proc-Xray/Scan: 			
Text Dx Proc-Operation: 			
Text Dx Proc-Lab Tests: 			
Text Dx Proc-Endoscopy: 			
Text Dx Proc-Path/Cyto: 			
Clinical TNM:  			
Clinical T:     			
Pathologic T:    			
Clinical N:     			
Pathologic N:    			
Clinical M:     			
Pathologic M:     			
Clinical Stage Group:  			
Staged By (Clin):  			
Other Stage:  			
Size of Tumor: 			
Positive nodes: 			
Peripheral Blood Inv.: 			
Nodes Examined: 			
Associated with HIV: 			
Extension:  			
Metastasis-1:  			
Lymph Nodes:  			
Metastasis-2:  			
General Summary Stage:  			
Metastasis-3:  			
Dx/Stging/Palliative Proc:  			
Surgery of Primary Site Date:  			
Surgical Approach:  			
Reconstruction/Restoration:  			
- Text Rx-Surgery/No Surgery:  			
- Text Rx-Other Cancer Directed Surgery:  			
Surgical Margins: 			
Reason for No Surgery:  			
Radiation Date:  			
Regional Dose:  			
Radiation tx not administered			
NA, brachytherapy/radioisotopes administered			
Dose unknown/unknown if administered			
Regional Treatment Modality:  			
Reason for No Radiation:  			
Sequence:  			
Radiation Treatment - (either radiation or prophylactic)  			
Target Place:  			
    Target Site:  			
    Radiation Source:  			
Total due to target:  			
    Predominant FXN size:  			
      Start Date:  			
      Stop Date:  			
- Text Rx-Rad (BEAM):  			
- Text Rx-Rad-Other:  			
Radiation Therapy to CNS DAte:  			
Chemotherapy Date: 			
Reason for No Chemotherapy:  			
Text-Rx-Chemo:  			
Hormone Therapy Date:  			
Reason for No Hormone Therapy:  			
Text-Rx-Hormone:  			
Immunotherapy Date:  			
Text-RX-Immunotherapy:  			
Other Therapy Date:  			
Text-Rx-Other:  			
Protocol Eligibility Status:  			
Protocol Participation:  			
Text Remarks:  			
Physician's Staging: 			
MD: 			
QA Selected: 			
QA Review: 			
QA Date: 			
Recurrence Date:  			
Distant Site 1:  			
Type of 1st Recurrence:  			
Distant Site 2:  			
Distant Site 3:  			
Subsequent Recurrence Date:  			
Type of Subsequent Recurrence:  			
**********  Print Abstract-Brief  **********			
Reporting Hospital: 			
Date of First Contact: 			
Histology: 			
Acc/Seq Number: 			
Medical Record Number: 			
Telephone:			
Type of Reporting Source: 			
Class of Case: 			
Age at Dx: 			
Birthplace: 			
Facility referred from: 			
Facility referred to: 			
Date Dx: 			
Following physician: 			
Primary surgeon: 			
Physician #3: 			
Physician #4: 			
Laterality: 			
Diagnostic confirmation: 			
Tumor size: 			
Extension: 			
Regional lymph nodes positive: 			
Regional lymph nodes examined: 			
Lymph nodes: 			
SEER Summary Stage 2000: 			
Sites of metastases: 			
Clinical TNM:     			
AJCC Stage (Clin):  			
AJCC Stage (Path):  			
FIRST COURSE OF TREATMENT SUMMARY:			
Dx/Staging/Palliative Proc: 			
Surgery of primary site: 			
Reason for no surgery: 			
Radiation: 			
Reason for no radiation: 			
Hormone Therapy: 			
Immunotherapy: 			
Other treatment: 			
Abstract Date: 			
Abstracter: 			
Date of Last Patient Contact: 			
AVAILABLE CONTACTS			
***********DEATH INFORMATION**********			
Date:  			
Cause of Death/Cancer: 			
ICD Cause:  			
Care Center: 			
ICD Revision: 			
Path/Autopsy (Gross & Micro):			
State Hospital No: 			
IDCO SITE: 			
GRADE: 			
Sequence Number: 			
DATE of LAST CONTACT: 			
VITAL STATUS: 			
ABSTRACTER: 			
ABSTRACT DATE: 			
Spanish origin: 			
CONTACT NAME			
Follow-up Status: 			
DATE LAST			
Site/Gp: 			
PATIENT SUMMARY			
Date of Last Contact or Death:			
Autopsy Date/Time: 			
Autopsy #: 			
Cause of Death: 			
Abstract Status: 			
Date Case Completed: 			
Primary Site: 			
Patient Summary/Abstract for: 			
** PATIENT IDENTIFICATION **			
Address at Dx: 			
Accession No: 			
Hospital No: 			
Accession Yr: 			
Primary Sequence No: 			
Phone Residence: 			
Marital Status DX: 			
Agent Orange Exp: 			
Ionizing Rad Exp: 			
Chemical Exp: 			
Asbestos Exp: 			
Persian Gulf Svc: 			
Middle East Svc: 			
Somalia Svc: 			
Comorbidity/Complication #1: 			
Comorbidity/Complication #2: 			
Comorbidity/Complication #3: 			
Comorbidity/Complication #4: 			
Comorbidity/Complication #5: 			
Comorbidity/Complication #6: 			
Primary Surgeon: 			
Following Physician: 			
** CANCER IDENTIFICATION **			
Date DX:  			
Histology:			
AFIP Submission:			
Primary Site:  			
** STAGE OF DISEASE AT DIAGNOSIS **			
Clinical TNM: 			
Pathologic TNM: 			
Clinical Stage Group: 			
Pathologic Stage Group: 			
Staged By (Clinical Stage): 			
Staged By (Pathologic Stage): 			
Other Stage: 			
Pathologic Extension: 			
Lymph Nodes: 			
General Summary Stage: 			
Metastasis-1: 			
Metastasis-2: 			
Metastasis-3: 			
** FIRST COURSE OF TREATMENT **			
First Course of Treatment Date:			
          Date of No Treatment:  			
        Surgery of Primary (F):  			
   Surgery of Primary @Fac (F):  			
              Surgical Margins:  			
       Scope of LN Surgery (F):  			
  Scope of LN Surgery @Fac (F):  			
      Surg Proc/Other Site (F):  			
 Surg Proc/Other Site @Fac (F):  			
         Reason for No Surgery:  			
                Regional Dose: 			
 Regional Treatment Modality:  			
Chemotherapy:  			
Chemotherapy @Fac:  			
Hormone Therapy:  			
Hormone Therapy @Fac:  			
Immunotherapy:  			
Immunotherapy @Fac:  			
Other Treatment:  			
Other Treatment @Fac:  			
Year Put on Protocol:  			
** SUBSEQUENT THERAPY **			
Subsequent Treatment Date:  			
Surgery of Primary Site: 			
Hema Trans/Endocrine Proc: 			
** FOLLOW-UP HISTORY **			
Cause of Death:  			
 1998 Patient Care Evaluation Study of Prostate Cancer			
1998 Patient Care Evaluation Study of Prostate Cancer			
8. PRIMARY PAYER AT DIAGNOSIS			
9. FAMILY HISTORY OF PROSTATE CANCER			
 8. PRIMARY PAYER AT DIAGNOSIS			
 9. FAMILY HISTORY OF PROSTATE CANCER			
 TABLE I - GENERAL INFORMATION			
9 4. POSTAL CODE AT DIAGNOSIS.........			
9 7. SPANISH ORIGIN...................			
18 8. PRIMARY PAYER AT DIAGNOSIS.......			
657 9. FAMILY HISTORY OF PROSTATE CANCER			
10. CLASS OF CASE			
11. SYMPTOMS PRESENT AT INITIAL DIAGNOSIS			
12. INITIAL METHODS OF DIAGNOSIS			
13. DIAGNOSTIC EVALUATION			
14. RESULTS OF MOST RECENT PRE-TREATMENT PSA TEST			
18. BEHAVIOR CODE(ICD-O-2)			
20. BIOPSY PROCEDURE			
21. GUIDANCE OF BIOPSY TO PRIMARY			
22. BIOPSY APPROACH FOR PRIMARY			
23. BIOPSY OF OTHER THAN PRIMARY			
24. DIAGNOSTIC CONFIRMATION			
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