Schedule 1—Prescribed information for centre, hospital or service
Name of centre, hospital or service
Hospital identification number
Hospital unit record number
Patient details:
Medicare number ( if known )
Individual Health Identifier ( if known )
Family name
Given name(s)
Maiden name ( if applicable )
Address
Postcode
Date of birth
Sex
Country of birth
Aboriginal or Torres Strait Islander status
Language spoken at home ( if known—please specify )
Details of doctor in charge of case:
Medicare provider number ( if known )
Name
Address
Telephone number
Details of general practitioner:
Medicare provider number ( if known )
Name
Address
Telephone number
Date of first admission for this cancer
Date of diagnosis of this cancer
Eastern Cooperative Oncology Group (ECOG) performance status at time of diagnosis ( if known )
Vital status
Date of discharge from centre/hospital/organisation
Investigations relevant to diagnosis of cancer
Primary site of cancer
Laterality of primary site of cancer
Morphology of primary cancer
Grade/differentiation of primary cancer
Stage of cancer at diagnosis
Cancer staging system ( to be reported in accordance with the "Victorian Cancer Staging Reporting Guidelines" as published by the Department of Health and Human Services from time to time )
Treatment details for each primary tumour:
Details of initial treatment
Details of treatment of recurrence(s) ( if any )
Cancer recurrence information:
Date of cancer recurrence
Site(s) of cancer recurrence
Name of person completing form
Date of completing form