page 1 asco survey on covid-19 in oncology registry (v2)

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ASCO Survey on Covid-19 in Oncology Registry (v2)

[Revised REDCap database (version 2.0) released October 26, 2020]

This REDCap data capture form is for collecting data on cancer patients with active cancer and those being treated inthe adjuvant setting. It should be used for submitting data on cancer patients who has had a confirmed case ofCOVID-19, and for follow-up information on patient outcomes.

Tips on data entry:

Complete the information as accurately as possible.

Follow-up data will be linked to baseline data using zip codes and patient's date of birth so accuracy in these fields isespecially important.

ICD-10 codes for cancer diagnosis are preferred to accurately categorize cancer types.

Some information may not be known (e.g., certain dates of clinical events). Do your best to approximate when anexact date is unknown.

Avoid using the "back" button on your browser: data will be entered twice.

If you need to submit an amended form, contact [email protected] with subject "ASCO Registry: amended form."

Please contact [email protected] if you have any problems with the data capture instruments

We can only accept data from practices that have a Data Use Agreement with ASCO. Data entered without a DataUse Agreement will be immediately deleted from the registry.

If your practice does not have a signed data use agreement with ASCO to contribute to the ASCO Registry, pleasecontact [email protected].

UPDATES TO THE DATA REGISTRY (October 2020)On October 23, 2020, the ASCO Registry Team sent out a memo to participating practices describing revisions to thedata forms. If you have not reviewed that memo, please review it now (see pdf link below).

[Attachment: "ASCO Registry Updates Version 2 - October 2020 (1).pdf"]

AS A REMINDER, THE REVISED SCHEDULE OF DATA ENTRY IS AS FOLLOWS:

INITIAL patient entry: The first submission of data from a patient; occurs as soon as possible after COVID-19 diagnosis, but any time afterthe patient has received or reported a positive COVID-19 test result FOLLOW-UP information on CANCER status: 1, 2, 3, 6, 9, and 12 months after COVID-19 diagnosis. ACUTE FOLLOW-UP information on COVID-19 status: 1, 2, and 3 months after COVID-19 diagnosis. LONG-TERM FOLLOW-UP information on COVID-19 status: 6, 9 and 12 months after COVID-19 diagnosis. ***** We are asking practices to complete an updated formregarding the patient's treatment plan at COVID-19 diagnosis for those patients whose baseline data was enteredinto the registry prior to 10/25/2020. To complete that form, please indicate that the patient is not a new patient andthen check "Re-entering data on the patient's cancer treatment plan at COVID-19 diagnosis. "ASCO staff have created a tool to track patient data entry (link below). You may use this to plan for and documentform submissions for each patient.

© 2021 American Society of Clinical Oncology (ASCO). All Rights Reserved worldwide.

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Please enter the PIN code that was provided to yourpractice for patient data entry: __________________________________



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Name of Practice: AIS Cancer CenterAnchorage Oncology CentreAugusta Health Center (Fisherville, VA)Augusta UniversityAultman HospitalBaptist Clinical Research InstituteBaptist Health Madisonville, Mahr Cancer CenterBayhealth Medical CenterBayonne Medical CenterBoone Hospital CenterBSA Harrington Cancer CenterCancer Center of Middle GeorgiaCancer Team -- Bellin HealthCarepoint Health Christ HospitalCarolinaEast Medical CenterCarteret Health CareCincinnati Children's Hospital Medical CenterColumbia Memorial Hospital/OHSU Knight CancerCenterEast Carolina UniversityEdward-Elmhurst HealthEmory UniversityFlorida Cancer Specialists & Research InstituteFlorida Precision Oncology (a Division of 21stCentury Oncology)Fox Chase Cancer CenterGene Upshaw Memorial Tahoe Forest Cancer CenterGoshen Center for Cancer CareGreat Lakes Cancer Management SpecialistsGreat Plains Health Callahan Cancer CenterGreater Baltimore Medical CenterHartford Healthcare Cancer InstituteHawaii Cancer CareHelen Diller Family Comprehensive Cancer Center,University of California, San FranciscoHematology Oncology Associates of Central New YorkHematology Oncology Associates of FredericksburgIllinois Cancer CareInfirmary Cancer CareJoliet Oncology-Hematology AssociatesKUMC (University of Kansas Medical Center)Lakeland HospitalsLevine Cancer Institute, Atrium HealthLifeBridge HealthLong Beach Memorial Medical CenterMayo ClinicMichiana Hematology OncologyMidwest Oncology AssociatesMonument Health - John T Vucurevich Cancer CareInstituteMosaic Life CareNebraska Cancer SpecialistsNebraska Hematology-OncologyNorthShore University Health SystemNorthwell Health Cancer InstituteOncology Hematology Care, Inc. (Cincinnati, Ohio)Orange Coast Memorial Medical CenterOSF Little Company of Mary HospitalPenn Medicine, Lancaster General HealthPenn Medicine, Princeton HealthPIH HealthPontchartrain Cancer CenterRogel Cancer Center, University of MichiganSaddleback Memorial Medical CenterSamaritan Health Services, CorvallisSarah Cannon Research Institute at HealthONESt. Agnes HealthcareTennessee OncologyThomas Jefferson University© 2021 American Society of Clinical Oncology (ASCO).

All Rights Reserved worldwide.


Tri-County Hematology and Oncology AssociatesTufts Medical CenterUniversity of Nebraska Medical CenterUniversity of North Carolina at Chapel HillVirginia Cancer Specialists (Alexandria, Virginia)Virginia Cancer Institute

Five digit zip code of oncology practice wherepatient is being treated __________________________________

Patient's date of birth (MM-DD-YYYY):__________________________________(Patient records will be linked using date ofbirth so please check for accuracy!)

Five digit zip code of patient's primary residence.__________________________________(Patient records will be linked using zip code soplease check for accuracy!)

The ASCO Registry has at least one registry patient This patient has not had any data entered intowho has recovered from COVID-19 and has had a registry before. I am reporting his/her baselinere-infection. Please read the options and select to forms.allow us to identify initial vs. a subsequent This patient has had data entered into registry atCOVID-19 illness. least once before and I am submitting a follow-up

form on an already reported infection.Is this patient new to the registry? If not, are you This patient already has data in the registry onsubmitting information on a new infection or an initial COVID-19 infection. I am reporting on afollow-up form? NEW COVID-19 infection in this patient.

Unique patient ID (provided to you at baseline entryfor this patient __________________________________

Date of most recent COVID-19 diagnosis:__________________________________

As of today, has the patient died or left your Yespractice for any reason such that you will no longer Nobe able to provide updates in the future on thepatient's COVID-19, cancer and treatment status?

Can you provide an update on the patient's COVID-19, Yes, there is new information I can provide oncancer or treatment status since last data entry? this patient since their last follow-up.Or, have you already entered all of the data for No, the last form submission included the lastthis patient at the last form submission? known information on this patient.

What type of follow-up forms are you submitting? Cancer and COVID-19 update at 1, 2, or 3 months[check all that apply] after COVID-19 diagnosis

Cancer and COVID-19 update at 6, 9 or 12 monthsafter COVID-19 diagnosisRe-entering data on the patient's cancer treatmentplan at COVID-19 diagnosis. [One-time re-entry perpatient; Only applicable to patients who wereenrolled in the registry on or before 10/24]

You selected 6, 9 or 12 month form. If any information about a patient's COVID-19 or cancer status from 30-90 daysafter COVID-19 diagnosis has NOT been entered, please also check the 1, 2, or 3 months follow-up form above, toensure data on the acute phase of COVID-19 is also entered for this patient (select above, in previous question).


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Has the patient for whom you are entering data had a Yesconfirmed case of COVID-19 (i.e., positive test for NoSARS-CoV-2)?

What is the patient's cancer status? The patient has active cancerThe patient is disease-free but is receivingadjuvant therapy within 1 year following surgicalresection (including hormonal treatments)Neither of the above

PARTICIPATION IN OTHER REGISTRIESHas information on this patient been entered into Yesanother COVID-19 & Cancer Registry? No

Unsure

To which registries have data been submitted for ASH Registry for Hematologic Malignanciesthis patient? CCC-19(check all that apply) Other

Unsure which registry

Which other registries?If more than one, separate with semi-colon (;). __________________________________

CONFIRM PRACTICEPlease confirm that you are entering data for a Yespatient treated at [name_of_practice]. Is this Nocorrect?(If not, please scroll to the top of the page andselect the correct practice name.)



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