Puerto Rico Central Cancer Registry Hospice Reporting Form
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1
2PRCCR Use Only
Y-CRS No._________________________ UPDate____________________
PUERTO RICO CENTRAL CANCER REGISTRY
HOSPICE REPORTING FORM
N-CRS
F/UP Date_________________ Letter Call
NO INFO Abstract Hold Processed by___________________________
Institution’s Information
Name of institution: ______________________________________ Attending MD_______________________________
Within Institution
(
)
Address_____________________________________________________________Phone # (___) __________________
Patient’s Information
Patient’s Name __________________________________________________ Date of Birth _______________________
(
)
Paternal & Maternal last names, Name, Middle name
MM/DD/YYYY
(
)
Social Security No. ___________________ MS □
Sex □
□
□
□
□
□
□
□
Single
Married
eparated
Divorced
Widowed
Unknown
Male
Female
Other
S
Phone # (___) _________________
Patient’s Address ____________________________
(Please select type of address) (Note: Please provide physical instead of postal address)
__________________________________
____________________________________
□
□
Patient’s home
Patient’s home
__________________________________
____________________________________
□
□
Relative
Relative
__________________________________
____________________________________
□
□
Nursing home
Nursing home
Diagnosis Information
Organ/system where cancer is located ___________________________Type of cancer______________________________________
(For example: Colon, Breast, Prostate, Blood, Lymph nodes)
(For example: Adenocarcinoma, Melanoma, Sarcoma, Brain tumor, Leukemia)
Additional information_________________________________________________________________________________________________
(Evidence of treatment)
Surgery
Chemotherapy
Radiotherapy
Other
Date FIRST DIAGNOSED ______________________ MD_____________________________________
(outside institution)
(MM/DD/YYYY)
(If the exact date on which the diagnosis was made is not available, then record an approximate date. Do not leave blank)
Follow Up Information
Patient was transferred from:
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify)
__________________________________________________________
Name of Institution
Physician: ______________________________________
Address
__________________________________________ Phone # (
)
__________________________________________
Patient was transferred to
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify) ______________________________________________________
Name of Institution __________________________________________________________________________________
Date of last contact with the patient __________________________ Vital Status □
□
Alive
Dead
(MM/DD/YYYY)
Form completed by ____________________________________ Position_________________________
(Please PRINT)
Date _____________________
(MM/DD/YYYY)
PRCCR 016 – Hospice Reporting Form
Rev. 04/2010
PUERTO RICO CENTRAL CANCER REGISTRY
PMB 711 Ave. De Diego #89 Suite105 San Juan, PR 00927-6345
Phone: (787) 772-8300 ext. 1103 Fax: (787) 522-3283
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