CTC Exam Form

Ryan Keefer

Modified on: Thu, 27 Feb, 2025 at 5:15 PM

The CTC Exam Form is used to collect all patient demographic information and exam/polyp information in a consolidated form. You can also access the exam form by clicking Register New Exam under Data Management in the CTC Registry menu, and entering in the patient information to search for, or create a new exam.

Complete the form by selecting from among the options presented on the form and filling in the blank fields. Fields marked with an asterisk (*) must be entered or the form cannot be submitted. Specific instructions for each field are as follows below.

Select the appropriate response.

Facility ID Number Registry Case Number	These fields are filled in automatically from the case registration form.
Exam Registration Date	Enter the date the paper form was completed.
3. Patient Information
SSN	To use the patient’s SSN, select the SSN radio button and enter the ID in the format NNN-NN-NNNN, with or without hyphens, where N is a digit. All digits are required.
Other Identification	Enter an identifier that uniquely identifies the patient, such as MRN. Entries in these fields cannot exceed 50 characters.
Last Name First Name	First and last names must be 50 characters or less. At least two characters must be from the characters "A"-"Z", "a"-"z", or a single quote ('). Additional characters may include a hyphen.
Middle Name	Middle Name is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "."
Old Medicare Beneficiary ID (MBID)	Indicate the the patient's Medicare Beneficiary ID issued prior to April 2018.
New Medicare Beneficiary ID (MBID)	Indicate the the patient's Medicare Beneficiary ID issued after April 2018. This is a combination of letters and numbers, 11 characters long.
*Date of Birth	Date of Birth must be at least three weeks prior to the current date.
*Patient Sex	Select the appropriate response.
Race	Enter the patient’s race as identified by the patient. If the patient identifies with more than one race, enter as many as apply. This field is optional.
Patient Ethnicity (Hispanic Origin)	Enter whether the patient is of Hispanic origin, as identified by the patient. This field is optional.
Health Insurance	Select the patient's health insurance, if available.
Education level	Select the patient's level of education, if available.
COVID vaccination/vaccination date	Indicate if the patient has received the COVID vaccine and the date of vaccination, if available.
COVID vaccine manufacturer	Select the appropriate response.
COVID vaccine site	Enter the location where the patient received the COVID vaccine, if available.
4. Examination Date
*Examination Date	Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date.
5A. General Information
*Type of Study	Select the appropriate response.
*Interpreting Physician	The physician’s name must be selected from the drop-down list. For a physician to be listed as the interpreting physician, he or she must be listed as a CTC participant in the physician dictionary. Refer to Manage Physician Dictionary and Users and Add Physicians to an Individual Registry for instructions on listing a physician as a CTC participant.
Did technique meet ACR guidelines?	Select the appropriate response. Click the icon for details.
Referred from incomplete colonoscopy	Select the appropriate response.
*CTDIvol	Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99.
Supine image acquisition Prone image acquisition *Decubitus image acquisition	Select the appropriate response.
5B. Post Examination and Adverse Events
*At least one polyp >= 10 mm	Select the appropriate response.
*Colonic perforation	If Yes is selected, then etiology, location, and whether the patient was symptomatic from perforation must be indicated.
C Score	Select the appropriate response.
E Score	Select the appropriate response.

Click the Submit button when the form is complete. You must correct any errors or the form will not be accepted by the registry. If no errors are detected a confirmation message appears and the case moves to Completed status.

ctc_exam_form 2024-07-13.pdf
(269 KB)

Complete the form by selecting from among the options presented on the form and filling in the blank fields. Fields marked with an asterisk (*) must be entered or the form cannot be submitted. Specific instructions for each field are as follows below.

Select the appropriate response.

Facility ID Number

Registry Case Number

These fields are filled in automatically from the case registration form.

Exam Registration Date

Enter the date the paper form was completed.

3. Patient Information

SSN

To use the patient’s SSN, select the SSN radio button and enter the ID in the format NNN-NN-NNNN, with or without hyphens, where N is a digit. All digits are required.

Other Identification

Enter an identifier that uniquely identifies the patient, such as MRN. Entries in these fields cannot exceed 50 characters.

*Last Name

*First Name

First and last names must be 50 characters or less. At least two characters must be from the characters "A"-"Z", "a"-"z", or a single quote ('). Additional characters may include a hyphen.

Middle Name

Middle Name is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "."

Old Medicare Beneficiary ID (MBID)

Indicate the the patient's Medicare Beneficiary ID issued prior to April 2018.

New Medicare Beneficiary ID (MBID)

Indicate the the patient's Medicare Beneficiary ID issued after April 2018. This is a combination of letters and numbers, 11 characters long.

*Date of Birth

Date of Birth must be at least three weeks prior to the current date.

*Patient Sex

Select the appropriate response.

Race

Enter the patient’s race as identified by the patient. If the patient identifies with more than one race, enter as many as apply. This field is optional.

Patient Ethnicity (Hispanic Origin)

Enter whether the patient is of Hispanic origin, as identified by the patient. This field is optional.

Health Insurance

Select the patient's health insurance, if available.

Education level

Select the patient's level of education, if available.

COVID vaccination/vaccination date

Indicate if the patient has received the COVID vaccine and the date of vaccination, if available.

COVID vaccine manufacturer

Select the appropriate response.

COVID vaccine site

Enter the location where the patient received the COVID vaccine, if available.

4. Examination Date

*Examination Date

Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date.

5A. General Information

*Type of Study

Select the appropriate response.

*Interpreting Physician

Did technique meet ACR guidelines?

Select the appropriate response. Click the icon for details.

Referred from incomplete colonoscopy

Select the appropriate response.

*CTDIvol

Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99.

*Supine image acquisition

*Prone image acquisition

*Decubitus image acquisition

Select the appropriate response.

5B. Post Examination and Adverse Events

*At least one polyp >= 10 mm

Select the appropriate response.

*Colonic perforation

If Yes is selected, then etiology, location, and whether the patient was symptomatic from perforation must be indicated.

C Score

Select the appropriate response.

Select the appropriate response.

Click the Submit button when the form is complete. You must correct any errors or the form will not be accepted by the registry. If no errors are detected a confirmation message appears and the case moves to Completed status.

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