Victorian Consolidated Regulations

IMPROVING CANCER OUTCOMES (DIAGNOSIS REPORTING) REGULATIONS 2015 - SCHEDULE 1

Schedule 1—Prescribed information for centre, hospital or service

Regulation 6(c)(i)

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